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Clinical indication-based diagnostic reference levels in CT: a systematic review
Abdul Alim1,2, Sook Sam Leong3,4, Ann Erynna Lema Thomas Sudin1
1Center for Medical Imaging Studies, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia.
BMJ Open
|February 4, 2026
Summary
National diagnostic reference levels based on clinical indications (NDRLci) in CT vary widely. Standardizing NDRLci development is crucial for improving CT dose comparability globally.
Area of Science:
- Radiological Physics and Medical Imaging
- Diagnostic Imaging and Radiation Protection
Background:
- National diagnostic reference levels based on clinical indications (NDRLci) are increasingly adopted globally following ICRP 2017 recommendations.
- Significant variations in NDRLci practices exist, necessitating a comparative analysis and identification of influencing factors.
Purpose of the Study:
- To compare international NDRLci practices for CT examinations.
- To identify factors influencing NDRLci values across different clinical indications.
- To propose evidence-based recommendations for developing standardized NDRLci.
Main Methods:
- Systematic literature review of studies published between 1996 and 2025.
- Searches conducted in PubMed, Web of Science, and Scopus.
- Adherence to PRISMA guidelines and critical appraisal using Joanna Briggs Institute tools.
Main Results:
- Eleven studies were included, analyzing 25 clinical indications across seven anatomical regions.
- Highest NDRLci (DLP) reported for total body CT in severe trauma (3830 mGy cm), lowest for sinusitis (70 mGy cm).
- Significant dose discrepancies observed for the same clinical indications.
Conclusions:
- Factors like CT technology, protocol parameters, and patient characteristics influence NDRLci.
- Standardized and optimized CT protocols are essential.
- International standardization of NDRLci development is critical for global comparability.
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