The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,

and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized .

Revised 2010 (Resolution 12)*

ACRASNR PRACTICE GUIDELINE FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) OF THE BRAIN
PREAMBLE These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. I. INTRODUCTION

This guideline was developed collaboratively by the American College of Radiology (ACR) and the American Society of Neuroradiology (ASNR). Computed tomography (CT) is a technology extensively used in neuroradiology that produces cross-sectional displays using ionizing radiation to generate images resulting from X-ray absorption by the specific tissues examined. CT offers a high degree of utility in the examination of the brain. This guideline outlines the principles for performing high-quality CT imaging of the brain in pediatric and adult patients, including advanced applications such as CT perfusion, CT volumetry, CT angiography, and CT venography. II. INDICATIONS

Indications for CT of the brain include, but are not limited to: A. Primary Indications 1. Acute head trauma. 2. Suspected acute intracranial hemorrhage.

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7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. B.

Vascular occlusive disease or vasculitis (including use of CT angiography and/or venography). Aneurysm evaluation. Detection or evaluation of calcification. Immediate postoperative evaluation following surgical treatment of tumor, intracranial hemorrhage, or hemorrhagic lesions. Treated or untreated vascular lesions. Suspected shunt malfunctions, or shunt revisions. Mental status change. Increased intracranial pressure. Headache. Acute neurologic deficits. Suspected intracranial infection. Suspected hydrocephalus. Congenital lesions (such as, but not limited to, craniosynostosis, macrocephaly, and microcephaly). Evaluating psychiatric disorders. Brain herniation. Suspected mass or tumor.

IV.

SPECIFICATIONS OF THE EXAMINATION

The supervising physician must have complete understanding of the indications, risks, and benefits of the examination, as well as alternative imaging procedures. The physician should be familiar with relevant ancillary studies that the patient may have undergone. (See the ACR Practice Guideline for Communication of Diagnostic Imaging Findings.) The physician performing CT interpretation must have a clear understanding and knowledge of the anatomy and pathophysiology relevant to the examination. The written or electronic request for CT of the brain should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination. The request for the examination must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patients clinical problem or question and consistent with the states scope of practice requirements. (ACR Resolution 35, adopted in 2006) A. General Considerations

Secondary Indications 1. When magnetic resonance imaging (MRI) imaging is unavailable or contraindicated, or if the supervising physician deems CT to be appropriate. 2. Diplopia. 3. Cranial nerve dysfunction. 4. Seizures. 5. Apnea. 6. Syncope. 7. Ataxia. 8. Suspicion of neurodegenerative disease. 9. Developmental delay. 10. Neuroendocrine dysfunction. 11. Encephalitis. 12. Drug toxicity. 13. Cortical dysplasia, and migration anomalies or other morphologic brain abnormalities.

For the pregnant or potentially pregnant patient, see the ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation. III. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL

CT protocols for brain imaging should be designed to answer the specific clinical question. The supervising physician should be familiar with the indications for each examination, relevant patient history, potential adverse reactions to contrast media, exposure factors, window and center settings, field of view, collimation, slice intervals, slice spacing (table increment) or pitch, and image reconstruction algorithms. Protocols should be reviewed and updated periodically to optimize the examination. B. Brain Imaging CT brain imaging may be performed with a sequential single-slice technique, multislice helical (spiral) protocol, or multidetector multislice algorithm. For CT of the brain, contiguous or overlapping axial slices should be acquired with a slice thickness of no greater than 5 mm. In the setting of trauma, images should be obtained and/or reviewed at window settings appropriate for demonstrating brain and bone abnormalities as well as PRACTICE GUIDELINE

See the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT).

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small subdural hematomas and soft tissue lesions (subdural windows). For imaging of the cranial base, an axial slice thickness as thin as possible, but no greater than 3 mm with spiral techniques and 2 mm with multidetector and nonspiral techniques, should be used for 2D reformatting or for 3D reconstruction. C. Contrast Studies Certain indications require administration of intravenous (IV) contrast media or intrathecal contrast (e.g., cisternography) during imaging of the brain. Intravenous contrast enhancement should be performed using appropriate injection protocols and in accordance with the ACRSPR Practice Guideline for the Use of Intravascular Contrast Media. Cerebrospinal fluid (CSF) contrast administration requires use of nonionic agents approved for intrathecal use and should be performed with regard to applicable guidelines as outlined in the ACRASNR Practice Guideline for the Performance of Myelography and Cisternography. D. Advanced Applications In addition to directly acquired axial images, reformatted images in coronal, sagittal, or other more complex planes may be constructed from the axial data set to answer specific clinical questions, or the images may be manipulated to allow selective visualization of specific tissues such as in CT perfusion, CT volumetry, CT angiography, or CT venography. Such applications are better performed with helical data sets using very thin slice thickness and overlapping reconstruction rather than routine axial sequential data. See the ACRASNR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic Imaging. V. DOCUMENTATION

3.

Interscan delay: not more than 4 seconds (may be longer if intravascular contrast media is not used). Limiting spatial resolution: must be measured to verify that it meets the unit manufacturers specifications. Limiting spatial resolution should be >10 lp/cm for a <24 cm display field of view (DFOV). Table pitch: no greater than 2:1 for most CT scanners. For advanced applications (e.g., perfusion imaging or CTA), cine-capable scanners are preferable with tube rotation 1 second and continuous cine imaging 60 seconds. See the ACRASNR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic Imaging.

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B. Patient monitoring equipment and facilities for cardiopulmonary resuscitation, including vital signs monitoring equipment, support equipment, should be immediately available. Appropriate emergency equipment and medications must be immediately available to treat adverse reactions associated with administered medications. The equipment and medications should be monitored for inventory and drug expiration dates on a regular basis. The equipment, medications, and other emergency support must also be appropriate for the range of ages or sizes in the patient populations. Radiologists, technologists, and staff members should be able to assist with procedures, patient monitoring, and patient support. A written policy should be in place for dealing with emergencies such as cardiopulmonary arrest. VII. RADIATION SAFETY IN IMAGING

Reporting should be in accordance with the ACR Practice Guideline for Communication of Diagnostic Imaging Findings. VI. EQUIPMENT SPECIFICATIONS

A. Performance Standards To achieve acceptable clinical CT scans of the brain, the CT scanner should meet or exceed the following specifications: 1. Scan times: per slice or image not more than 2 seconds. Slice thickness: minimum slice thickness 2 mm or less.

Radiologists, medical physicists, radiologic technologists, and all supervising physicians have a responsibility to minimize radiation dose to individual patients, to staff, and to society as a whole, while maintaining the necessary diagnostic image quality. This concept is known as as low as reasonably achievable (ALARA). Facilities, in consultation with the medical physicist, should have in place and should adhere to policies and procedures, in accordance with ALARA, to vary examination protocols to take into account patient body habitus, such as height and/or weight, body mass index or lateral width. The dose reduction devices that are available on imaging equipment should be active; if not, manual techniques should be used to moderate the exposure while maintaining the necessary diagnostic

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image quality. Periodically, radiation exposures should be measured and patient radiation doses estimated by a medical physicist in accordance with the appropriate ACR Technical Standard. (ACR Resolution 17, adopted in 2006 revised in 2009, Resolution 11) VIII. QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION CONTROL, AND PATIENT EDUCATION

Kavita K. Erickson, MD Scott H. Faro, MD Blaise V. Jones, MD John E. Jordan, MD Edward E. Kassel, MD, FACR Stephen A. Kieffer, MD, FACR Eric J. Russell, MD, FACR Jeffrey A. Stone, MD Robert W. Tarr, MD Patrick A. Turski, MD, FACR Comments Reconciliation Committee Michael M. Raskin, MD, MPH, JD, MBA, FACR, Chair Kimberly E. Applegate, MD, MS, FACR Howard B. Fleishon, MD, MMM, FACR John E. Jordan, MD Alan D. Kaye, MD, FACR Paul A. Larson, MD, FACR Lawrence A. Liebscher, MD, FACR Carolyn C. Meltzer, MD, FACR Suresh K. Mukherji, MD, FACR Christopher J. Roth, MD Michael I. Rothman, MD Lawrence N. Tanenbaum, MD, FACR Suggested Reading (Additional articles that are not cited in the document but that the committee recommends for further reading on this topic) 1. Quality Assurance for Diagnostic Imaging Equipment. Bethesda, Md.: National Council on Radiation Protection (NCRP); 1988. NCRP Report 99. Alberico RA, Loud P, Pollina J, Greco W, Patel M, Klufas R. Thick-section reformatting of thinly collimated helical CT for reduction of skull baserelated artifacts. AJR 2000;175:1361-1366. Calzado A, Rodriguez R, Munoz A. Quality criteria implementation for brain and lumbar spine CT examinations. Br J Radiol 2000;73:384-395. Castillo M. Contrast enhancement in primary tumors of the brain and spinal cord. Neuroimaging Clin N Am 1994;4:63-80. Chamberlain MC. Pediatric AIDS: a longitudinal comparative MRI and CT brain imaging study. J Child Neurol 1993; 8:175-181. Eastwood JD, Lev MH, Azhari T, et al. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Radiology 2002;222:227-236. Ertl-Wagner B, Eftimov L, Blume J, et al. Cranial CT with 64-, 16-, 4-single-slice CT systems-comparison of image quality and posterior fossa artifacts in routine brain imaging with standard protocols. Eur Radiol 2008;18:1720-1726. Ezzeddine MA, Lev MH, McDonald CT, et al. CT angiography with whole brain perfused blood volume imaging: added clinical value in the assessment of acute stroke. Stroke 2002;33:959-966. PRACTICE GUIDELINE

Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control, and Patient Education appearing under the heading Position Statement on QC & Improvement, Safety, Infection Control, and Patient Education on the ACR web page (http://www.acr.org/guidelines). For specific issues regarding CT quality control, see the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT). Equipment monitoring should be in accordance with the ACRAAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment. ACKNOWLEDGEMENTS This guideline was revised according to the process described under the heading The Process for Developing ACR Practice Guidelines and Technical Standards on the ACR web page (http://www.acr.org/guidelines) by the Guidelines and Standards Committee of the Commission on Neuroradiology in collaboration with the Subcommittee on Standards and Guidelines of the ASNR. Principal Drafter: John E. Jordan, MD ACR Guidelines and Standards Committee Suresh K. Mukherji, MD, FACR, Chair Jacqueline A. Bello, MD, FACR Mark H. Depper, MD Carol A. Dolinskas, MD, FACR Sachin Gujar, MD John E. Jordan, MD Stephen A. Kieffer, MD, FACR Edward J. OBrien, Jr., MD, FACR Jeffrey R. Petrella, MD John L. Ulmer, MD R. Nick Bryan, MD, PhD, FACR, Chair, Commission ASNR Guidelines Committee Suresh K. Mukherji, MD, FACR, Chair John D. Barr, MD Jacqueline A. Bello, MD, FACR Carol A. Dolinskas, MD, FACR 4 / CT Brain

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26. Jordan MJ, Lightfoote JB, Jordan JE. Quality outcomes of reinterpretation of brain CT imaging studies by subspecialty experts in neuroradiology. J Natl Med Assoc 2006;98:1326-1328. 27. Kornreich L, Shapira A, Horev G, Danziger Y, Tyano S, Mimouni M. CT and MR evaluation of the brain in patients with anorexia nervosa. AJNR 1991;12:1213-1216. 28. Laissy JP, Soyer P, Parlier C, et al. Persistent enhancement after treatment for cerebral toxoplasmosis in patients with AIDS: predictive value for subsequent recurrence. AJNR 1994;15:1773-1778. 29. Lallemand DP, Brasch RC, Char DH, Norman D. Orbital tumors in children. Characterization by computed tomography. Radiology 1984;151:85-88. 30. Lindgren A, Norrving B, Rudling O, Johansson BB. Comparison of clinical and neuroradiological findings in first-ever stroke. A population-based study. Stroke 1994; 25:1371-1377. 31. Lipper MH, Kishore PR, Enas GG, Domingues da Silva AA, Choi SC, Becker DP. Computed tomography in the prediction of outcome in head injury. AJR 1985;144:483-486. 32. Mahesh M, Scatarige JC, Cooper J, Fishman EK. Dose and pitch relationship for a particular multislice CT scanner. AJR 2001;177:1273-1275. 33. Marks MP, Napel S, Jordan JE, Enzmann DR. Diagnosis of carotid artery disease: preliminary experience with maximum-intensity-projection spiral CT angiography. AJR 1993;160:1267-1271. 34. Marshall LF, Marshall SB, Klauber MR, et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 1992;9 Suppl 1:S287-292. 35. Matsumoto M, Kodama N, Endo Y, et al. Dynamic 3D-CT angiography. AJNR 2007;28:299-304. 36. Matsumoto M, Kodama N, Sakuma J, et al. 3D-CT arteriography and 3D-CT venography: the separate demonstration of arterial-phase and venous-phase on 3D-CT angiography in a single procedure. AJNR 2005;26:635-641. 37. Maytal J, Bienkowski RS, Patel M, Eviatar L. The value of brain imaging in children with headaches. Pediatrics 1995;96:413-416. 38. McCrohan JL, Patterson JF, Gagne RM, Goldstein HA. Average radiation doses in a standard head examination for 250 CT systems. Radiology 1987; 63:263-268. 39. Mullins ME, Schaefer PW, Sorensen AG, et al. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology 2002;224:353-360. 40. Murayama K, Katada K, Nakane M. et al. Wholebrain perfusion CT performed with a prototype 256detector row CT system: initial experience. Radiology 2009;250:202-211. 41. Prabhakar R, Haresh KP, Ganesh T, Joshi RC, Julka PK, Rath GK. Comparison of computed tomography CT Brain / 5

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56. Taphoorn MJ, Heimans JJ, Kaiser MC, de Slegte RG, Crezee FC, Valk J. Imaging of brain metastases. Comparison of computerized tomography (CT) and magnetic resonance imaging (MRI). Neuroradiology 1989;31:391-395. 57. Wintermark M, Maeder P, Thiran JP, Schnyder P, Meuli R. Quantitative assessment of regional cerebral blood flows by perfusion CT studies at low injection rates: a critical review of the underlying theoretical models. Eur Radiol 2001;11:1220-1230. 58. Wolf M, Ziegengeist S, Michalik M, Bornholdt F, Michalik S, Meffert B. Classification of brain tumours by CT-image Walsh spectra. Neuroradiology 1990;32:464-466. *Guidelines and standards are published annually with an effective date of October 1 in the year in which amended, revised or approved by the ACR Council. For guidelines and standards published before 1999, the effective date was January 1 following the year in which the guideline or standard was amended, revised, or approved by the ACR Council. Development Chronology for this Guideline 2004 (Resolution 32) Amended 2006 (Resolution 17, 35) Revised 2009 (Resolution 27) Revised 2010 (Resolution 12)

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