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## Complete Summary

#### GUIDELINE TITLE

Epilepsy.

#### BIBLIOGRAPHIC SOURCE(S)

Karis JP, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont
PD, Hackney DB, Jordan JE, Mukherji SK, Turshi PA, Wippold FJ II,
Zimmermann RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Epilepsy. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2006. 8 p. \[44 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Tanenbaum L, Drayer BP,
Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA,
Masaryk T, Pomeranz SJ, Seidenwurm D, Masdeu JC. Epilepsy. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):459-70.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Epilepsy

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurological Surgery\
Neurology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with epilepsy

#### TARGET POPULATION

Patients with epilepsy

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Magnetic resonance imaging (MRI), brain, without and with contrast

2.  Magnetic resonance angiography (MRA), head

3.  Functional MRI (fMRI), brain

4.  Single-photon emission computed tomography (SPECT), brain

5.  Positron emission tomography with fluorodeoxyglucose (FDG-PET),
    brain

6.  Magnetoencephalography/Magnetic source imaging (MEG/MSI)

7.  Computed tomography (CT), head, without and with contrast

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Epilepsy**

**Variant 1: Chronic epilepsy, poor therapeutic response. Surgery
candidate.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, brain, without  8                    
  contrast                                 

  MRI, brain, without  8                    
  and with contrast                        

  FDG-PET, brain       7                   May be helpful in pre-op planning.

  CT, head, without    6                    
  and with contrast                        

  fMRI, brain          5                   May be helpful in pre-op planning.

  SPECT, brain         5                   May be helpful in pre-op planning.

  MEG/MSI              5                   Data probably equivalent to BOLD
                                           and SPECT

  CT, head, without    5                    
  contrast                                 

  MRA, head            3                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: New onset of seizure. ETOH, and /or drug related.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, brain, without  8                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  MRI, brain, without  7                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  CT, head, without    6                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  CT, head, without    5                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  MRA, head            2                    

  fMRI, brain          2                    

  SPECT, brain         2                    

  FDG-PET, brain       2                    

  MEG/MSI              2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: New onset seizure. Aged 18--40 years.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, brain, without  8                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  MRI, brain, without  7                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  CT, head, without    6                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  CT, head, without    5                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  SPECT, brain         4                    

  FDG-PET, brain       4                    

  MRA, head            2                    

  fMRI, brain          2                    

  MEG/MSI              2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: New onset seizure. Older than age 40.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, brain, without  8                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  MRI, brain, without  7                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  CT, head, without    5                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice.

  SPECT, brain         4                    

  FDG-PET, brain       4                    

  CT, head, without    3                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice.

  MRA, head            2                    

  fMRI, brain          2                    

  MEG/MSI              2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: New onset seizure. Focal neurological deficit.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, brain, without  8                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice

  MRI, brain, without  8                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice

  CT, head, without    7                   In the acute or emergency setting,
  and with contrast                        CT may be the imaging study of
                                           choice

  CT, head, without    6                   In the acute or emergency setting,
  contrast                                 CT may be the imaging study of
                                           choice

  SPECT, brain         3                    

  FDG-PET, brain       3                    

  MRA, head            2                    

  fMRI, brain          2                    

  MEG/MSI              2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

The classification of epileptic seizures by the International League
Against Epilepsy was last revised in 1989 (see Appendix A in the
original guideline document for an outline of the International
Classification of Epileptic Seizures). The classification is important
because etiologic diagnosis, appropriate treatment, and accurate
prognostication all depend on the correct identification of seizures and
epilepsy. There are two main seizure types: partial seizures and primary
generalized seizures. Partial (formerly referred to as focal) seizures
show either clinical or electroencephalography (EEG) evidence of onset
from a localized area within the cerebral hemisphere. The nature of the
signs and symptoms in most cases indicate the region of the brain
involved by the epileptic process. Partial seizures are designated as
simple or complex. Complex partial seizures are associated with loss of
consciousness. In simple seizures, the epileptic process is usually
confined to neocortical structures, and the limbic system and brainstem
are spared. Most simple seizures are less disabling than those
associated with loss of consciousness. Partial seizures can spread and
develop into secondarily generalized seizures. Primary generalized
seizures originate simultaneously from both cerebral hemispheres, and
clinical manifestations involve both sides of the body. Primary
generalized seizures first occur at an earlier age, and are more likely
to be associated with a family history of seizure disorders, but are
less likely to be associated with focal cerebral lesions. Some seizures
remain unclassified because the underlying mechanism of their origin or
propagation is unknown.

Certain types of seizure disorders are likely to be associated with
structural brain lesions, including tumors, infection, infarction,
traumatic brain injury, vascular malformations, developmental
abnormalities, and seizure-associated brain pathology (see Appendix B in
the guideline document), whereas others are not. Hence, knowledge of
seizure types helps to determine whether neuroimaging is clinically
indicated and what type of study is appropriate.

While the imaging evaluation of epilepsy was greatly advanced by the
clinical introduction of computed tomography (CT) in the early 1970\'s,
because of its superior soft tissue contrast, multiplanar imaging
capability, and lack of beam hardening artifacts, virtually all the
substrates of epilepsy are visualized with greater sensitivity and
accuracy by magnetic resonance imaging (MRI). As a result, MRI has
become the modality of choice for high-resolution structural imaging in
epilepsy. Although routine evaluation techniques of all clinically
available scanner field strengths may be sufficient for determination of
mass lesions, optimized protocols for scans obtained on high-field
(\>1.5 T) scanners may be necessary for evaluating partial complex
epilepsy, requiring scrutiny of the hippocampus and temporal lobe for
atrophy and subtle signal alteration, as well as for detecting certain
structural abnormalities such as cortical dysplasias, hamartomas, and
other developmental abnormalities. Anatomic imaging identifies focal
abnormalities in up to 51% of patients with partial epilepsy. With the
widespread clinical availability of high-performance MRI systems, a
comprehensive MRI examination, with functional techniques providing
additional information, adding corroborative information, and improving
overall accuracy, may in the future be of even greater value in
epilepsy.

Although the data provided by MRI are essential in the presurgical
evaluation of patients with medically refractory epilepsy, structurally
detectable abnormalities are absent in many patients. In these patients,
functional studies provide useful information on localization of the
seizure focus. Functional imaging techniques, including positron
emission tomography (PET), single-photon emission computed tomography
(SPECT), magnetic source imaging (MSI), and functional MRI (fMRI), have
contributed to the presurgical evaluation of patients with epilepsy.

Clinical PET with fluorodeoxyglucose (FDG) provides a measure of glucose
uptake and thus metabolism. A seizure focus will typically manifest as a
focus of hypometabolism on interictal (between episodes of seizure
activity) examinations and will be seen as a focus of increased
metabolism on ictal (during seizure) examinations. Interictal FDG-PET is
sensitive (84%) and specific (86%) by electroencephalogram (EEG)
criteria to temporal lobe epilepsy (TLE) and 33% sensitive and 95%
specific to extratemporal epilepsy. By comparison, structural imaging
using a variety of MR field strengths and techniques yielded a
sensitivity and specificity of 55% and 78%. SPECT utilizing perfusion
agents such as 99mTc-HMPAO or 99mTc-Neurolite, as well as bolus MRI
perfusion provide an assessment of regional cerebral blood flow rather
than brain metabolism. A seizure focus will typically manifest as a
focus of hypoperfusion on interictal examinations and will be seen as a
focus of increased activity on ictal examinations. The utility of
isolated interictal cerebral perfusion assessment in patients without
anatomic imaging abnormality is limited. The use of ictal/interictal
subtraction imaging with coregistration on MRI and image-guided surgery
datasets is proving to be more useful than interictal perfusion imaging
alone. Injection of the blood flow agent within 90 seconds of seizure
onset does, however, appear to be required to demonstrate the expected
localized increase in cerebral perfusion. The use of perfusion
techniques in epilepsy is therefore limited because of the technological
challenge of injecting EEG-monitored patients within 90 seconds of
seizure onset.

fMRI techniques include phosphorus and proton spectroscopy (MRS),
perfusion, and blood oxygen level dependent (BOLD) activation. The
widespread application of most of these techniques in clinical practice
depends on the impending widespread availability of high-performance MR
imagers capable of performing fast echo-planar pulse sequences (EPIs),
as well as substantial data post-processing capabilities.

MRS is a set of noninvasive techniques for in vivo chemical analysis of
the brain, some of which can be performed on standard-performance
clinical MR units. Although MRS has been used extensively for the past
30 years in molecular physics and chemistry, its application to the
study of epilepsy is relatively recent. Widely available proton and
phosphorus single-voxel techniques have consistently demonstrated
metabolite changes in the epileptogenic region of the brain. MRS or
chemical shift imaging (CSI) allows simultaneous acquisition of spectra
from all brain regions. The pictorial display of MRS information
facilitates comparison of the epileptogenic zone with the remainder of
the brain and provides localizing information. Chemical shift imaging is
not yet widely available in clinical practice. Initial studies suggest
that both proton and phosphorus MRS will be useful adjunctive
presurgical tests for localizing seizure foci in patients with partial
epilepsy, particularly in difficult cases, potentially reducing the need
for intracranial-depth electrode EEG recordings and those with
extratemporal seizure foci.

Only magnetoencephalography (MEG) and EEG are capable of measuring
epileptic brain activity directly and with high temporal resolution. The
temporal resolution of PET, SPECT, and fMRI is poor by comparison
(sec-min). Recent improvements in MEG technology now allow whole brain
coverage and overlay of source information on MR or CT images (with
MSI). Available data indicate that interictal MEG can be an effective
tool for localization of seizure foci in patients with medical
refractory partial epilepsy. Significant shortcomings include limited
availability, high cost, and assessment limited to relatively
superficial and tangential sources. Nonetheless, MSI does provide
unique, accurate, and useful information about epileptogenic regions in
the brain, and where available, has a potential role in the diagnostic
workup of most patients with epilepsy.

**Abbreviations**

-   BOLD, blood oxygen level dependent

-   CT, computed tomography

-   ETOH, ethyl alcohol

-   FDG-PET, fluorodeoxyglucose-positron emission tomography

-   fMRI, functional magnetic resonance imaging

-   MEG, magnetoencephalography

-   MRA, magnetic resonance angiography

-   MSI, magnetic source imaging

-   PET, positron emission tomography

-   SPECT, single-photon emission computed tomography

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with epilepsy

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (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 exams 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
U.S. Food and Drug Administration (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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Karis JP, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont
PD, Hackney DB, Jordan JE, Mukherji SK, Turshi PA, Wippold FJ II,
Zimmermann RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Epilepsy. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2006. 8 p. \[44 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Neurologic
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: John P. Karis, MD; David J. Seidenwurm, MD; Patricia C.
Davis, MD; James A. Brunberg, MD; Robert L. DeLaPaz, MD; Pr. Didier
Dormont; David B. Hackney, MD; John E. Jordan, MD; Suresh Kumar
Mukherji, MD; Patrick A. Turski, MD; Franz J. Wippold II, MD; Robert D.
Zimmerman, MD; Michael W. McDermott, MD; Michael A. Sloan, MD, MS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Tanenbaum L, Drayer BP,
Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA,
Masaryk T, Pomeranz SJ, Seidenwurm D, Masdeu JC. Epilepsy. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):459-70.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/EpilepsyDoc3.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on July 31, 2001. The information was
verified by the guideline developer as of August 24, 2001. This summary
was updated by ECRI Institute on April 26, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008