Normal CT brain report template
A normal CT brain report in four versions: routine non-contrast, contrast-enhanced, head trauma, and an older patient with expected age-related change. Placeholders in [ ] are the parts to confirm on every study.
CT BRAIN WITHOUT CONTRAST
INDICATION: [ ]
COMPARISON: None.
TECHNIQUE: Multiple axial images are obtained from the skull base to the vertex without contrast. CT scan was performed according to ALARA (as low as reasonably achievable).
FINDINGS:
The brain shows normal morphology, attenuation, and volume for age. No evidence of space occupying lesion, hemorrhage, edema, mass effect, midline shift, extra axial collection, or hydrocephalus is noted. Ventricles, sulci, and basal cisterns are symmetric and normal in size and configuration.
The gray-white matter differentiation is preserved.
Visualized paranasal sinuses and mastoid air cells are well aerated. Orbital contents are within normal limits. Bony structures are intact.
IMPRESSION:
1. No evidence of acute intracranial abnormality is demonstrated.CT BRAIN WITH CONTRAST
INDICATION: [ ]
COMPARISON: None.
TECHNIQUE: Multiple contiguous axial images are obtained from the skull base to the vertex after administration of IV contrast. If IV contrast material had not been administered, the likelihood of detecting abnormalities relevant to the patient's condition would have been substantially decreased. CT scan was performed according to ALARA (as low as reasonably achievable).
FINDINGS:
The brain demonstrates normal morphology, attenuation, and volume for age. No evidence of space occupying lesion, hemorrhage, edema, mass effect, midline shift, extra axial collection, or hydrocephalus is noted. Ventricles, sulci, and basal cisterns are symmetric and normal in size and configuration.
No abnormal enhancement is seen following administration of IV contrast.
The paranasal sinuses and mastoid air cells are well aerated. Orbital contents are within normal limits. The bony calvarium is intact.
IMPRESSION:
1. No acute intracranial abnormality or abnormal enhancement.CT BRAIN WITHOUT CONTRAST (TRAUMA)
INDICATION: [ ]
COMPARISON: None.
TECHNIQUE: Multiple axial images are obtained from the skull base to the vertex without contrast. CT scan was performed according to ALARA (as low as reasonably achievable).
FINDINGS:
No acute intracranial hemorrhage, extra-axial collection, or hemorrhagic contusion. No mass effect or midline shift.
The brain shows normal morphology, attenuation, and volume for age.
No evidence of space occupying lesion or hydrocephalus is noted.
Ventricles, sulci, and basal cisterns are symmetric and normal in size and configuration.
The gray-white matter differentiation is preserved.
Visualized paranasal sinuses and mastoid air cells are well aerated. Orbital contents are within normal limits. Bony structures are intact.
IMPRESSION:
1. No evidence of acute intracranial abnormality is demonstrated.CT BRAIN WITHOUT CONTRAST (OVER 60 YEARS)
INDICATION: [ ]
COMPARISON: None.
TECHNIQUE: Multiple axial images are obtained from the skull base to the vertex without contrast. CT scan was performed according to ALARA (as low as reasonably achievable).
FINDINGS:
Diffuse age appropriate neuroparenchymal atrophy is noted in the form of prominent sulci, cisterns, fissures and ventricles.
[Patchy / confluent] areas of periventricular and deep white matter hypodensities are noted, most consistent with chronic small vessel ischemic changes.
The brain otherwise shows normal morphology and attenuation. No evidence of space occupying lesion, hemorrhage, edema, mass effect, midline shift, extra axial collection, or hydrocephalus is noted. Ventricles, sulci, and basal cisterns are symmetric and normal in size and configuration.
The gray-white matter differentiation is preserved.
Visualized paranasal sinuses and mastoid air cells are well aerated. Orbital contents are within normal limits. Bony structures are intact.
IMPRESSION:
1. No evidence of acute intracranial abnormality is demonstrated.
2. Diffuse age related neuroparenchymal atrophy with small vessel ischemic changes.Plain text. Pastes cleanly into PACS, RIS, PowerScribe, Word, or a browser. Fields in [ ] need your input. Add it to your collection to keep your own edited copy and share it with colleagues.
What to check before you sign a normal CT brain
A normal template is only safe if you have looked at everything it mentions.
- Gray-white matter differentiation. Early ischemia blurs it before an infarct is obvious. Check the insular ribbon and the lentiform nucleus on narrow windows.
- Every compartment for blood. Thin subdurals along the tentorium and falx and subarachnoid blood in the interpeduncular cistern and sylvian fissures are the classic misses. A subdural window helps.
- Ventricles, sulci, and basal cisterns. Effaced cisterns suggest raised pressure. Ventricles enlarged out of proportion to the sulci suggest hydrocephalus.
- Posterior fossa. Beam hardening makes it hard to read, which is why it gets skipped. Look at the cerebellum and fourth ventricle anyway.
- Bone windows. Skull base and temporal bone fractures hide on soft tissue windows. Always review bone algorithm images.
- Sinuses, mastoids, and orbits. After trauma, a fluid level in the sphenoid sinus can be the only sign of a skull base fracture.
Common mistakes with this template
The impression contradicts the findings
A small subdural is dictated in the findings, but the template impression still reads 'No acute intracranial abnormality'. Read the impression last, every time.
Comparison left as 'None'
A prior scan from last week exists, but the template line stays. Fix the comparison line before anything else.
The wrong version for the study
A non-contrast template on a contrast study, or the routine version on a trauma head where the team needed the fracture line stated.
Age-blind normals
Leaving out obvious small vessel change in an older patient makes it look like a new finding on the next report.
Questions
What should a normal CT brain report include?
Technique (with or without contrast), comparison, then findings for the extra-axial spaces, hemorrhage, ventricles, cisterns, parenchyma, midline, posterior fossa, calvarium, and the visualized sinuses and orbits, followed by an impression that answers the clinical question.
Is 'no acute intracranial abnormality' the same as a normal scan?
Not always. It means nothing urgent such as bleeding, a new stroke, or mass effect was found. Chronic findings like age-related change can still be present. Patients with questions about their own scan should ask the doctor who ordered it.
Should the impression say 'normal' or 'no acute intracranial abnormality'?
Many departments prefer 'no acute intracranial abnormality' on non-contrast CT because it is honest about what the study can exclude. 'Normal' is fine for a genuinely normal study. Follow your department's convention.
Who wrote this template
Written by Dr Gayathri Priyadharshinee, radiologist, from the normal templates she uses in her own reporting. You are free to copy it and adapt the wording to your department's style.
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