Most Emergency Head CT Requests Found Inadequate in Italian Study

A new analysis from Italy indicates that nearly 80 percent of physician requests for emergency head CT scans are inadequate, highlighting both overuse and the need for better clinical justification. The findings, published in Insights into Imaging, add to concerns about the rising utilization of CT imaging, associated costs, and unnecessary radiation exposure.

Head CT scans have become increasingly common in emergency medicine. Utilization has climbed by about 30 percent globally since 2007, with one Italian emergency department reporting that referrals more than doubled between 2008 and 2022. To investigate the appropriateness of these requests, researchers at a public hospital in Trento evaluated the quality of CT requisitions over a four-month period in 2022.

The team, led by radiologist Carlo Cosimo Quattrocchi, MD, of the University of Trento, reviewed more than 2,900 emergency head CT requests. Each was scored using the Reason for Exam Imaging Reporting and Data System (RI-RADS), and assessed for clinical appropriateness according to American College of Radiology (ACR) criteria.

The results revealed that only about 21 percent (620 requests) were considered adequate in quality, while nearly 79 percent (2,288 requests) were inadequate. For around 400 cases, appropriateness could not be judged due to missing clinical data. Among the remaining 2,500 requests, roughly 25 percent were deemed “usually not appropriate” in terms of clinical indication.

When broken down further, the study showed a strong correlation between referral quality and appropriateness. About 84 percent of scans categorized as adequate (RI-RADS A or B) also met appropriateness standards, compared with about 70 percent of scans deemed inadequate (RI-RADS C or D).

Notably, among patients whose scans were classified as inappropriate, 98 percent did not show signs of acute cerebral disease on imaging. The most common presenting symptoms for these requests were headache and syncope, conditions often managed conservatively. In addition, positivity rates were significantly higher for appropriate requests compared with inappropriate ones (11 percent vs. 1 percent), reinforcing the value of guideline-based justification.

“Excessive head CT requests in the ED cause needless radiation, pollution, and costs,” Quattrocchi and co-authors wrote. “Integrating guidelines and prospective justification with clear documentation in patient records, along with improved staff training and a no-blame culture, are key to reducing unnecessary imaging.”

The researchers suggested that defensive medicine is a key driver of inappropriate imaging. Emergency physicians, often under pressure, may request scans under the assumption that they provide legal protection, even in cases with little clinical justification. The authors argued that improving referral quality could help mitigate this risk, especially by ensuring clear diagnostic queries are provided when ordering imaging.

The study concludes that reform is urgently needed to align head CT utilization with evidence-based guidelines. By addressing overuse, healthcare systems may reduce patient exposure to unnecessary radiation, cut costs, and ensure CT resources are available for those most likely to benefit.