ACR Appropriateness Criteria® Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid Hemorrhage
ACR Appropriateness Criteria® Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid Hemorrhage
ACR Appropriateness Criteria® Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid Hemorrhage
Abstract
Cerebrovascular disease is a broad topic. This document focuses on the imaging recommendations for the varied clinical scenarios
involving intracranial aneurysms, vascular malformations, and vasculitis, which all carry high risk of morbidity and mortality. Additional
imaging recommendations regarding complications of these conditions, including subarachnoid hemorrhage and vasospasm, are also
a o
Director, Head and Neck Imaging, University of California Los Angeles, Albany ENT & Allergy Services, PC, Albany, New York; American
Los Angeles, California. Academy of Otolaryngology-Head and Neck Surgery; President, Albany
b
Panel Chair and Program Director, Diagnostic Radiology Residency ENT & Allergy Services, PC.
p
Program, Montefiore Medical Center, Bronx, New York. Associate Chief, Hospital Medicine, Albert Einstein College of Medicine
c
Panel Vice-Chair, Uniformed Services University, Bethesda, Maryland. Montefiore Medical Center, Bronx, New York; Internal medicine physician.
d q
Ohio State University, Columbus, Ohio; Chief of Neuroradiology & MRI Clinical Site Director, Department of Radiology, Allen Hospital, New
at WRNMMC; and Associate Chief of Neuroradiology for AIRP. York Presbyterian, New York, New York; and Columbia University
e
Michigan State University, East Lansing, Michigan, American College of Medical Center, New York, New York.
r
Emergency Physicians. University of Cincinnati Medical Center, Cincinnati, Ohio.
f s
Ottawa Hospital Research Institute and the Department of Radiology, The Specialty Chair, Atlanta VA Health Care System and Emory University,
University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Atlanta, Georgia.
Radiologists. Corresponding author: Luke Ledbetter MD, Department of Radiology,
g
Director of Quality, Radiology, Emory University, Atlanta, Georgia; ACR David Geffen School of Medicine at UCLA, Ronald Reagan Medical
YPS Communications Liaison. Center, 757 Westwood Plaza, Suite 1621D, Los Angeles, CA, 90095-7532;
h
Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert. e-mail: [email protected].
i
Mayo Clinic, Rochester, Minnesota. The American College of Radiology seeks and encourages collaboration
j
University of New Mexico, Albuquerque, New Mexico, American College with other organizations on the development of the ACR Appropriateness
of Physicians. Criteria through society representation on expert panels. Participation by
k
Chair, Department of Radiology, Einstein Healthcare Network, Phila- representatives from collaborating societies on the expert panel does not
delphia, Pennsylvania. necessarily imply individual or society endorsement of the final document.
l
University of California San Diego Medical Center, San Diego, California. Reprint requests to: [email protected].
m
Oregon Health & Science University, Portland, Oregon. The authors state that they have no conflict of interest related to the material
n
University of North Carolina School of Medicine, Chapel Hill, North discussed in this article. Drs Chakraborty, Ducruet, and Setzen are partners;
Carolina; American Academy of Neurology; Chair, Writing Group, and all other authors are non-partner/non-partnership track/employees.
American Heart Association/American Stroke Association Guidelines for The ACR Appropriateness Criteria documents are updated regularly. Please
the Early Management of Patients with Acute Ischemic Stroke, 2016- go to the ACR website at www.acr.org/ac to confirm that you are accessing
2019. the most current content.
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.
Variant 1. Known acute subarachnoid hemorrhage (SAH) on CT. Next imaging study.
Appropriateness Appropriateness
Category Name 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 5 The individual ratings are too dispersed from the panel median. The different
(Disagreement) label provides transparency regarding the panel’s recommendation. “May be
appropriate” is the rating category and a rating of 5 is assigned.
Usually Not 1, 2, or 3 The imaging procedure or treatment is unlikely to be indicated in the specified
Appropriate clinical scenarios, or the risk-benefit ratio for patients is likely to be
unfavorable.
RRL Adult Effective Dose Estimate Range (mSv) Pediatric Effective Dose Estimate Range (mSv)
O 0 0
☢ <0.1 <0.03
☢☢ 0.1-1 0.03-0.3
Note: Relative radiation level (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 (eg, region of the body exposed to ionizing radiation, the imaging guidance that is
used). The RRLs for these examinations are designated as “varies.”