Common Reporting Phrases for Head CT

A noncontrast head CT report often answers an urgent clinical question: Is there hemorrhage, mass effect, hydrocephalus, or traumatic osseous injury? The report therefore needs...

RadPhrases Editorial TeamJuly 31, 20264 min read

Modular reporting phrases converging into a coherent radiology report at a clinical workstation

REPORTING PHRASES · HEAD CT

A noncontrast head CT report often answers an urgent clinical question: Is there hemorrhage, mass effect, hydrocephalus, or traumatic osseous injury? The report therefore needs to be concise while remaining systematic enough to cover critical negative and positive findings.

The examples below show how reporting sentences can be structured. The sensitivity limitations of the technique should be remembered, particularly for early ischemia, small-volume subarachnoid hemorrhage, and assessment of the posterior fossa and skull base.

Important usage note The sentences in this article are educational examples. Prefabricated text does not replace image review or the radiologist’s clinical judgment. Laterality, level, size, technical adequacy, comparison, and impression must be reverified for every case.

Technique and comparison

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Scenario / purpose	Example reporting phrase and usage note
Basic technique	Noncontrast head CT was acquired in the axial plane and evaluated using multiplanar reformatted images.
Motion artifact	Assessment is partially limited by motion artifact, particularly in the posterior fossa.
Metal artifact	Beam-hardening artifact from dental hardware limits assessment of structures adjacent to the skull base.
Comparison	The examination was compared with the head CT dated ....
Noncontrast limitation	The examination is noncontrast; parenchymal and meningeal enhancement patterns cannot be assessed.

Scenario / purpose	Example reporting phrase and usage note
No acute hemorrhage	No acute intracranial hemorrhage is identified.
Intraparenchymal hematoma	There is an acute intraparenchymal hematoma in the right basal ganglia measuring approximately ... × ... × ... mm.
Perihematomal edema	The hematoma is accompanied by surrounding vasogenic edema and effacement of the adjacent sulci.
Subarachnoid hemorrhage	Hyperdensities compatible with acute subarachnoid hemorrhage are present in the bilateral frontal sulci and interhemispheric fissure.
Subdural hematoma	There is an acute subdural hematoma along the left frontoparietal convexity, measuring up to ... mm in thickness.
Epidural hematoma	A biconvex epidural hematoma is present in the right temporal region, measuring up to ... mm in thickness.
Intraventricular hemorrhage	Intraventricular hemorrhage is present in the occipital horns of the lateral ventricles.

Scenario / purpose	Example reporting phrase and usage note
No midline shift	No midline shift is present.
Midline shift	There is approximately ... mm of leftward midline shift at the level of the septum pellucidum.
Sulcal effacement	There is diffuse sulcal effacement and hemispheric edema in the right cerebral hemisphere.
Basal cisterns	The basal cisterns are patent.
Herniation	There is effacement of the ipsilateral perimesencephalic cisterns with contralateral displacement of the midbrain, concerning for uncal herniation.
Posterior fossa	There is compression of the fourth ventricle and narrowing of the posterior fossa cisterns.

Scenario / purpose	Example reporting phrase and usage note
No large acute infarct	No definite parenchymal hypoattenuation suggesting a large acute cortical infarct is identified.
Possible early ischemia	Subtle loss of gray-white matter differentiation in the left insular cortex is suspicious for early ischemia.
Hyperdense artery	Hyperdensity of the left middle cerebral artery M1 segment is suspicious for thrombus; correlation with clinical and angiographic findings is recommended.
Limitation for acute ischemia	The limited sensitivity of noncontrast CT for early acute ischemia should be considered; further evaluation may be required when clinical suspicion persists.
Chronic infarct	Chronic encephalomalacic and gliotic changes are present in the right parieto-occipital region.

Scenario / purpose	Example reporting phrase and usage note
Normal ventricles	The ventricular system is within normal limits for age.
Hydrocephalus	There is marked enlargement of the lateral and third ventricles with periventricular transependymal CSF flow.
Ex vacuo enlargement	Ventricular and sulcal prominence is compatible with cerebral volume loss.
Asymmetric enlargement	The left lateral ventricle is mildly larger than the right, without a definite obstructive finding.
Atrophy	There is diffuse cerebral volume loss, greater than expected for age, with prominence of the sulci and ventricular system.

Common Reporting Phrases for Head CT

Technique and comparison

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Phrases for acute hemorrhage

Assessment of mass effect and herniation

Acute ischemia and early signs

Ventricles, hydrocephalus, and atrophy

Chronic parenchymal changes

Trauma and osseous structures

Quick check before signing the report

References

Clinical use note

Stop rewriting these phrases from scratch

Scenario / purpose	Example reporting phrase and usage note
Chronic microangiopathy	Hypoattenuating areas in the periventricular and deep white matter are compatible with chronic microangiopathic ischemic change.
Lacunar infarct	There is a small hypoattenuating focus in the left lentiform nucleus compatible with a chronic lacunar infarct.
Encephalomalacia	Chronic encephalomalacic change is present in the right frontal lobe, with ex vacuo enlargement of the adjacent ventricle.
Calcification	Symmetric physiologic calcifications are present in the bilateral basal ganglia.
Postsurgical change	There are changes of left frontotemporal craniotomy with underlying postoperative encephalomalacia.

Scenario / purpose	Example reporting phrase and usage note
No acute fracture	No acute displaced calvarial fracture is identified on bone-window images.
Linear fracture	A nondisplaced linear fracture is present in the right parietal bone.
Skull base	No definite acute fracture of the skull base is identified; assessment is limited in areas affected by artifact.
Hemosinus	A hyperdense fluid level in the left maxillary sinus may be related to trauma.
Scalp hematoma	There is a subgaleal hematoma in the right parietal region.

Technique and comparison

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Continue learning

Phrases for acute hemorrhage

Assessment of mass effect and herniation

Acute ischemia and early signs

Ventricles, hydrocephalus, and atrophy

Chronic parenchymal changes

Trauma and osseous structures

Quick check before signing the report

References

Clinical use note

Stop rewriting these phrases from scratch