ACR Appropriateness Criteria®
Clinical Condition: Head Trauma
Variant 1: Minor or mild acute closed head injury (GCS ≥13), without risk factors or neurologic deficit.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
7 |
Known to have low yield. |
|
MRI head without contrast |
4 |
|
O |
MRA head and neck without contrast |
3 |
Rarely indicated with mild trauma. |
O |
MRA head and neck without and with contrast |
3 |
|
O |
CT head without and with contrast |
3 |
|
|
CTA head and neck with contrast |
3 |
Rarely indicated with mild trauma. |
|
MRI head without and with contrast |
2 |
|
O |
CT head with contrast |
1 |
|
|
X-ray head |
1 |
|
|
FDG-PET/CT head |
1 |
|
|
US transcranial with Doppler |
1 |
|
O |
Arteriography cervicocerebral |
1 |
|
|
Tc-99m HMPAO SPECT head |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Minor or mild acute closed head injury, focal neurologic deficit and/or risk factors.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
MRI head without contrast |
6 |
For problem solving. |
O |
MRA head and neck without contrast |
5 |
If vascular injury is suspected. For problem solving. |
O |
MRA head and neck without and with contrast |
5 |
If vascular injury is suspected. For problem solving. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CTA head and neck with contrast |
5 |
If vascular injury is suspected. For problem solving. |
|
MRI head without and with contrast |
3 |
|
O |
CT head without and with contrast |
2 |
|
|
CT head with contrast |
1 |
|
|
Tc-99m HMPAO SPECT head |
1 |
|
|
FDG-PET/CT head |
1 |
|
|
US transcranial with Doppler |
1 |
|
O |
X-ray head |
1 |
|
|
Arteriography cervicocerebral |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Moderate or severe acute closed head injury.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
MRI head without contrast |
6 |
|
O |
MRA head and neck without contrast |
5 |
|
O |
MRA head and neck without and with contrast |
5 |
See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CTA head and neck with contrast |
5 |
|
|
CT head without and with contrast |
2 |
|
|
MRI head without and with contrast |
2 |
|
O |
X-ray head |
2 |
|
|
CT head with contrast |
1 |
|
|
US transcranial with Doppler |
1 |
|
O |
FDG-PET/CT head |
1 |
|
|
Arteriography cervicocerebral |
1 |
|
|
Tc-99m HMPAO SPECT head |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Mild or moderate acute closed head injury, child <2 years old.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
MRI head without contrast |
7 |
Diffusion weighted imaging especially helpful for nonaccidental trauma. |
O |
MRI head without and with contrast |
4 |
Potentially useful in suspected nonaccidental trauma. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
MRA head and neck without contrast |
4 |
If vascular abnormality suspected. |
O |
MRA head and neck without and with contrast |
4 |
If vascular abnormality is suspected. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CTA head and neck with contrast |
4 |
If vascular abnormality is suspected. |
|
X-ray head |
2 |
Appropriate as part of skeletal survey in suspected nonaccidental trauma. May be appropriate when screening for patients suspected of having penetrating head trauma or foreign bodies. |
|
CT head without and with contrast |
2 |
|
|
CT head with contrast |
1 |
|
|
FDG-PET/CT head |
1 |
|
|
Tc-99m HMPAO SPECT head |
1 |
|
|
US transcranial with Doppler |
1 |
|
O |
Arteriography cervicocerebral |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Subacute or chronic closed head injury with cognitive and/or neurologic deficit(s).
Radiologic Procedure |
Rating |
Comments |
RRL* |
MRI head without contrast |
8 |
|
O |
CT head without contrast |
6 |
|
|
Tc-99m HMPAO SPECT head |
4 |
For selected cases. |
|
FDG-PET/CT head |
4 |
For selected cases. |
|
MRA head and neck without contrast |
4 |
For selected cases. |
O |
MRA head and neck without and with contrast |
4 |
For selected cases. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CTA head and neck with contrast |
4 |
For selected cases. |
|
MRI head without and with contrast |
3 |
|
O |
CT head without and with contrast |
2 |
|
|
CT head with contrast |
2 |
|
|
X-ray head |
2 |
|
|
MRI functional (fMRI) head without contrast |
2 |
|
O |
US transcranial with Doppler |
1 |
|
O |
Arteriography cervicocerebral |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Closed head injury, rule out carotid or vertebral artery dissection.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CTA head and neck with contrast |
8 |
|
|
MRA head and neck without contrast |
8 |
Add T1 neck images. |
O |
MRA head and neck without and with contrast |
8 |
Add T1 neck images. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
MRI head without contrast |
8 |
Include diffusion-weighted images. |
O |
CT head without contrast |
8 |
|
|
CT head without and with contrast |
6 |
Consider perfusion. |
|
Arteriography cervicocerebral |
6 |
For problem solving. |
|
MRI head without and with contrast |
6 |
See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CT head with contrast |
4 |
Consider perfusion. |
|
X-ray head |
2 |
|
|
Tc-99m HMPAO SPECT head |
1 |
|
|
US transcranial with Doppler |
1 |
|
O |
FDG-PET/CT head |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Penetrating injury, stable, neurologically intact.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
CTA head and neck with contrast |
7 |
|
|
MRA head and neck without contrast |
6 |
If there is no MRI contraindication. |
O |
MRA head and neck without and with contrast |
6 |
If there is no MRI contraindication. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
Arteriography cervicocerebral |
5 |
If vascular injury is suspected. |
|
MRI head without contrast |
5 |
If there is no MRI contraindication. |
O |
CT head without and with contrast |
4 |
Consider perfusion. |
|
MRI head without and with contrast |
4 |
If there is no MRI contraindication. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
X-ray head |
4 |
|
|
CT head with contrast |
2 |
|
|
US transcranial with Doppler |
1 |
|
O |
Tc-99m HMPAO SPECT head |
1 |
|
|
FDG-PET/CT head |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 8: Skull fracture.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
CTA head and neck with contrast |
7 |
If vascular injury is suspected. |
|
MRI head without contrast |
6 |
|
O |
X-ray head |
5 |
For selected cases. |
|
MRI head without and with contrast |
4 |
Useful if infection suspected. See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CT head without and with contrast |
4 |
|
|
MRA head and neck without contrast |
4 |
|
O |
MRA head and neck without and with contrast |
4 |
See statement regarding contrast in the text below under "Anticipated Exceptions." |
O |
CT head with contrast |
2 |
|
|
US transcranial with Doppler |
1 |
|
O |
Tc-99m HMPAO SPECT head |
1 |
|
|
Arteriography cervicocerebral |
1 |
|
|
FDG-PET/CT head |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Summary of Literature Review
Introduction/Background
Craniocerebral injuries are a common cause of hospital admission following trauma, and are associated with significant long-term morbidity and mortality, particularly in the adolescent and young adult population. Neuroimaging plays an essential role in identifying and characterizing these brain injuries. Computed tomography (CT) remains essential for detecting lesions that require immediate neurosurgical intervention (e.g., acute subdural hematoma) as well as those that require in-hospital observation and medical management. For patients with minor head injury (Glasgow Coma Scale [GCS] score of 13-15), the New Orleans Criteria and the Canadian CT Head Rule are clinical guidelines with high sensitivity for detecting injuries that require neurosurgical intervention, and they offer a potential reduction in unnecessary CT scans. All guidelines have a trade-off between sensitivity and specificity for detection of significant findings in head-injured patients.
Other imaging modalities, such as magnetic resonance imaging (MRI), depict nonsurgical pathology not visible on CT. Single photon emission computed tomography (SPECT), positron emission tomography (PET), and transcranial Doppler (TCD) have a complementary role in the assessment of nonacute brain injury. Because cervical spine trauma may accompany a head injury, cervical spine imaging is indicated for patients with head injury who have signs, symptoms, or a mechanism of injury that might result in spinal injury, and in those who are neurologically impaired. See the National Guideline Clearinghouse (NGC) summary of American College of Radiology (ACR) Appropriateness Criteria® Suspected Spine Trauma for details.
Skull Radiography
One study developed and prospectively tested a management strategy for selecting patients who may benefit from skull radiography following head trauma was and offered recommendations for selecting patients who should receive CT scanning following head injury. The effect of that study was to shift the focus of neuroimaging of head trauma away from skull radiography and toward recognition of intracranial pathology as demonstrated by CT scanning. Skull radiography is useful for imaging of calvarial fractures, penetrating injuries, and radiopaque foreign bodies.
Computed Tomography
CT's advantages for evaluating the head-injured patient include its sensitivity for demonstrating mass effect, ventricular size and configuration, bone injuries, and acute hemorrhage regardless of location (i.e., parenchymal, subarachnoid, subdural, or epidural spaces). Other advantages include its widespread availability, rapidity of scanning, and compatibility with other medical and life support devices. Computer-generated reformatted images may have value in detecting intracranial hemorrhages, especially along bone surfaces that approximate the transverse plane of axial images.
CT limitations include insensitivity in detecting small and predominantly nonhemorrhagic lesions associated with trauma such as contusion, particularly when they are adjacent to bony surfaces (e.g., frontal lobes adjacent to the orbital roof, anterior temporal lobes adjacent to the greater sphenoid wing). Likewise, diffuse axonal injuries (DAIs) that result in small focal lesions throughout the cerebral hemispheres, corpus callosum, and upper brainstem and cerebellum often go undetected on CT. CT is relatively insensitive for detecting increased intracranial pressure or cerebral edema and for early demonstration of hypoxic-ischemic encephalopathy (HIE) that may accompany moderate or severe head injury. Potential risks of unnecessary exposure to ionizing radiation warrant judicious patient selection for CT scanning as well as radiation dose management.
There is now a general consensus that patients identified as having moderate or high risk for intracranial injury should undergo early postinjury noncontrast CT for evidence of intracerebral hematoma, midline shift, or increased intracranial pressure. A number of clinical criteria are used to predict patient risk categories for intracranial injury. There is an inverse relationship between declining clinical or neurologic status as described by the GCS and the incidence and severity of CT abnormalities related to head injury.
Although experienced physicians can often predict the likelihood of an abnormal CT scan in moderate or severe head injury, clinical selection criteria of patients with minor or mild injury (e.g., GCS score ≥13) who harbor significant intracranial pathology and/or require acute surgical intervention have been problematic. Rapid CT scanning is readily available in most hospitals that treat head-injured patients; thus the routine use of CT has been advocated as a screening tool to triage minor or mild head-injured patients who require hospital admission or surgical intervention from those who can be safely discharged without hospital admission. Although CT triage of head-injured patients who require hospital admission offers a reduced burden on inpatient hospital services at lower cost than routine hospital admission for observation, the result is greater CT use in the emergency setting. In the minor head injury setting with a GCS score of 15, the New Orleans Criteria found a 100% sensitivity for CT identification of an acute trauma lesion using risk factors of headache, vomiting, drug or alcohol intoxication, older than age 60, short-term memory deficit, physical findings of supraclavicular trauma, and/or seizure. One study reported 100% sensitivity for detecting neurosurgical and/or clinically important brain injury in subjects with a GCS score of 13-15 based on high-risk factors of failure to reach a GCS score of 15 within 2 hours, suspected open skull fracture, 2 or more vomiting episodes, sign of basal skull fracture, or age ≥65 years. A prospective trial of the Canadian CT Head Rule in Canadian emergency departments did not result in reduced rates of CT scanning in head trauma.
Clinical criteria for scanning of children with head injury have been less reliable than those for adults, particularly for children younger than age two. For this reason, more liberal use of CT scanning has been suggested for pediatric patients. On the other hand, this must be balanced with the higher risk of radiation exposure in childhood via judicious patient selection for scanning as well as size-based management of radiation dose. For pediatric patients, one study reported 95.4% sensitivity for intracranial injury using factors, including dizziness, skull defect, sensory deficit, mental status change, bicycle-related injury, age younger than 2 years, GCS score <15, and evidence of basilar skull fracture.
Noncontrast head CT plays an essential role in the evaluation of children with suspected physical injury from child abuse; appropriateness criteria for imaging of child abuse have already been described (see the pediatric sections of the ACR Appropriateness Criteria®).
Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema. CT has a role in subacute or chronic head injury for depicting atrophy, focal encephalomalacia, hydrocephalus, and chronic subdural hematoma.
Cerebral Angiography, CT Angiography, and MR Angiography
Since the development of CT in the mid-1970s, the need for cerebral angiography for head injury has dramatically declined. Cerebral angiography has a role in demonstrating and managing traumatic vascular injuries such as pseudoaneurysm, dissection, fistulae, or diagnosis and neurointerventional treatment of uncontrolled hemorrhage. Vascular injuries typically occur with penetrating trauma (e.g., gunshot wound or stabbing), basal skull fracture, or trauma to the neck, although dissection and traumatic aneurysm may follow blunt or closed head trauma.
Dynamic spiral CT angiography (CTA) and magnetic resonance angiography (MRA) have a role as less invasive screening tools for detecting traumatic intracranial, skull base, and/or neck vascular lesions. Intracranial and neck MRA with fat-suppressed T1-weighted neck MR are helpful for screening vascular lesions such as thromboses, pseudoaneurysms, fistulae, or dissection. CTA of the aortic arch and neck vasculature may reveal carotid or vertebral dissection, although angiography remains the gold standard for depicting dissection. Independent predictors for arterial vascular injury as depicted by craniocerebral CTA in blunt trauma include cervical facet subluxation/dislocation, fracture lines approaching an artery, and high-impact injury mechanism. Cerebral infarction is an infrequent accompaniment of head injury, and patterns of infarction suggest that direct vascular compression related to intracranial mass lesions is the most common underlying mechanism.
Magnetic Resonance Imaging
MRI in imaging of head trauma is hindered by its limited availability in the acute trauma setting, long imaging times, sensitivity to patient motion, incompatibility with various medical and life support devices, and relative insensitivity to subarachnoid hemorrhage. Other factors include the need for MRI-specific monitoring equipment and ventilators, and the risk of scanning patients with certain indwelling devices (e.g., cardiac pacemaker, cerebral aneurysm clips) or occult foreign bodies. In part, these limitations can be overcome by situating MRI scanners close to emergency care areas with appropriate design and equipment for managing acutely injured patients. MRI advances such as open-bore geometry, faster imaging sequences, and improved patient monitoring equipment allow a greater role for MRI in closed head injuries.
MRI is very sensitive for detecting and characterizing subacute and chronic brain injuries. The number, size, and location of MR abnormalities in subacute head injury have been used to predict the recovery outcome of post-traumatic vegetative state. While CT is sensitive for detecting injuries requiring a change in treatment, MRI is also used for acute head-injured patients with nonsurgical, medically stable pathology. Hemosiderin-sensitive T2-weighted gradient echo and susceptibility-weighted sequences are helpful for imaging small or subacute or chronic hemorrhages. Diffusion-weighted sequences improve detection of acute infarction associated with head injury. Fluid-attenuated inversion recovery (FLAIR) images are more sensitive than conventional MRI sequences for depicting subarachnoid hemorrhage and for lesions bordered by cerebrospinal fluid (CSF). One study found that the addition of gadolinium enhancement offered no significant advantage for lesion detection or characterization compared with noncontrast MRI images in head-injury patients.
The soft tissue detail offered by MRI is superior to that of CT for depicting nonhemorrhagic primary lesions such as contusions, for detecting secondary effects of trauma such as edema and HIE, and for imaging of DAI. DAI results from a shear-strain pattern of acceleration-deceleration with characteristic lesions in increasing order of injury severity in the: 1) cerebral white matter and gray-white matter junction, 2) corpus callosum, particularly the splenium, and 3) dorsal upper brain stem and cerebellum.
Although management of surgical injuries is not likely to be altered by the substitution of MRI for CT, superior depiction of nonsurgical lesions with MRI may affect medical management and predict the degree of neurologic recovery. Early MRI (i.e., within 4 weeks) providing evidence of DAI following moderate to severe head trauma correlated with negative prognosis only in subjects with brain stem injury. Diffusion-weighted MRI and apparent diffusion coefficient (ADC) mapping depict cytotoxic injury almost immediately. In acute brain trauma, focal contusion and DAI may show restricted diffusion and evolve over time to atrophy or encephalomalacia. Perfusion imaging with CT or MRI may prove helpful as a marker for disorders of vascular autoregulation or ischemia. Diffusion tensor imaging and MR spectroscopy (MRS) are ancillary tools that may offer additional insight into the biochemical and structural patterns of injury following head trauma, as well as prognosis.
Functional Imaging Modalities
Some reports suggest that there is a role for functional imaging techniques (SPECT, PET, perfusion CT, perfusion MR, functional MRI, MRS) in assessing cognitive and neuropsychologic disturbances as well as recovery following head trauma. SPECT studies may reveal focal areas of hypoperfusion that are discordant with findings of MRI or CT. On the basis of these results, some investigators suggest that these functional imaging techniques may explain or predict post-injury neuropsychologic and cognitive deficits that are not explained by anatomic abnormalities detected by MRI or CT. Furthermore, focal lesions demonstrated by SPECT offer objective evidence of organic injury in patients whose neuroimaging studies are otherwise normal. One study found that a pattern of global reduction of cerebral blood flow detected by SPECT predicted a poor likelihood of recovery for patients who are in a persistent vegetative state due to head injury. Likewise, PET studies with fluorine-18-labeled fluorodeoxyglucose (FDG) tracer may reveal more extensive abnormalities than CT or MRI. SPECT and PET do not provide the anatomic detail or image resolution of CT or MRI for demonstrating acute or neurosurgical lesions of closed head injury, so their use is generally limited to subacute or chronic patients.
One reported study found that perfusion MRI may depict reduced blood volume in head-injured patients who do not show evidence of anatomic abnormalities on CT or MRI. Perfusion CT may likewise show abnormalities in cerebral blood flow after trauma that may correlate with outcome in mildly head-injured patients with disabling symptoms, although its clinical role is uncertain given the disadvantages of radiation exposure and its limited area of brain coverage. A reduction in N-acetylaspartate (NAA)/creatine ratio and NAA on MRS may occur in areas of brain injury, with lactate in areas of brain ischemia. MRS limitations include limited anatomic coverage and lack of correlation of ratios with outcome in mild head injury at 6 months.
TCD sonography offers a noninvasive bedside evaluation of cerebral blood flow velocity and resistance in the major proximal vessels of the circle of Willis. Several investigators have suggested that TCD can be used to monitor early changes in blood flow velocities that may relate to vasospasm, hypervolemia, low velocity state, or edema, especially in management of the acutely brain-injured patient.
Summary
- CT is the most appropriate initial study for acute evaluation of the head-injured patient who may harbor lesion(s) that require immediate neurosurgical intervention. Early and sometimes repeat CT scanning may be required if there is clinical and/or neurologic deterioration, especially in the first 72 hours after injury.
- Cervical spine imaging is often appropriate in head-injured patients. See the NGC summary of the ACR Appropriateness Criteria® Suspected Spine Trauma for details.
- MR has a role in subacute or chronic injury for detecting and characterizing non-neurosurgical lesions such as HIE and DAI, and may have a role in prognosis.
- Vascular imaging (CTA, MRA, and angiography) may depict traumatic vascular injuries in the setting of penetrating injury, blunt neck trauma, and/or skull base or cervical spine fracture.
- Advanced imaging techniques (perfusion CT, perfusion MRI, SPECT, and PET) have utility in better understanding selected head-injured patients but are not considered routine clinical practice at this time.
Anticipated Exceptions
Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the ACR Manual on Contrast Media (see the "Availability of Companion Documents" field).
Abbreviations
- CT, computed tomography
- CTA, computed tomography angiography
- FDG-PET, fluorodeoxyglucose-positron emission tomography
- GCS, Glasgow Coma Scale
- HMPAO, hexamethylpropyleneamine oxime
- MRA, magnetic resonance angiography
- MRI, magnetic resonance imaging
- SPECT, single photon emission tomography
- Tc, technetium
- US, ultrasound
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.” |