The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates.
Supported in part by the National Institute of Biomedical Imaging and Bioengineering (NIBIB).
=========================================================================== * CT Brain * http://www.radreport.org/template/0000004 Type: Reporting template Language: English (en) Modified date: 2012-03-28 Creator: Flanders AE, et al. Contributor: Bozkurt S [coder] Contributor: Kahn CE Jr [editor] Contributor: American Society of Neuroradiology (ASNR) This file is part of the "RSNA Radiology Reporting Templates." The RSNA Radiology Reporting Templates are licensed without charge under the RSNA's license agreement (the "License"); you may not use this file except in compliance with the License (http://www.radreport.org/license.pdf). Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. See the License for the specific language governing permissions and limitations under the License. Copyright (c) 2013, Radiological Society of North America, Inc. (RSNA) ALL RIGHTS RESERVED =========================================================================== Clinical History * Medical history * Risk factors * Allergies, if relevant * Reason for exam, including medical necessity: [headache | stroke | dizziness | trauma] Imaging Technique * Time of image acquisition * Imaging device [MR, CT] * Image acquisition parameters, such as device settings, patient positioning, interventions (e.g., Valsalva maneuver) * Contrast materials and other medications administered (including name, dose, route, and time of administration) * Radiation dose Comparison * Date and type of previous exams reviewed, if applicable Observations * Extra axial spaces: [normal in size and morphology for the patient's age* | widened] * Hemorrhage: [none* ; subdural ; subarachnoid; epidural, intraventricular, parenchymal] * Ventricular system: [normal in size and morphology for the patient's age* | enlarged | small] * Basal cisterns: [normal* | enlarged | small] * Cerebral parenchyma: [normal*; microvascular changes; infarction; encephalomalacia; gliosis; hemorrhage] * Midline shift: [none* | leftward shift | rightward shift] * Cerebellum: [normal*] * Brainstem: [normal*] Other: * Calvarium: [normal*; non-depressed fracture; depressed fracture; osteolysis; sclerosis] * Vascular system: [normal* | vascular calcifications (CT) | appropriate arterial and dural sinus flow voids (MR)] * Visualized Paranasal sinuses: [clear* | scattered mild inflammatory mucosal thickening] * Visualized Orbits: [normal*] * Visualized upper cervical spine: [normal*] * Sella and skull base: [normal* | partially empty sella | left/right mastoid air cell fluid] Summary (or Impression) * An itemized list of key observations, including any recommendations.