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 Team4 min read
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
| 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. |
Phrases for acute hemorrhage
| 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. |
Assessment of mass effect and herniation
| 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. |
Acute ischemia and early signs
| 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. |
Ventricles, hydrocephalus, and atrophy
| 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. |
Chronic parenchymal changes
| 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. |
Trauma and osseous structures
| 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. |
Quick check before signing the report
- Were acute hemorrhage, mass effect, midline shift, and the basal cisterns assessed separately?
- Were gray-white matter differentiation and vascular hyperdensity checked for signs of early ischemia?
- Is ventricular enlargement more consistent with atrophy or obstruction?
- In trauma, were the bone windows and extracranial soft tissues reviewed?
- Were the limitations of the technique explained when relevant?
References
- American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. Revised 2025. Source (opens in a new tab)
- Hartung MP, Bickle IC, Gaillard F, Kanne JP. How to Create a Great Radiology Report. RadioGraphics. 2020;40(6). Source (opens in a new tab)
- American College of Radiology. ACR–SPR Practice Parameter for Performing and Interpreting Diagnostic Computed Tomography (CT). Revised 2022. Source (opens in a new tab)
Clinical use note
This content is educational and is not patient-specific medical advice. Every phrase, template, classification result, and recommendation must be verified and adapted by a physician using the complete examination, clinical context, current guidelines, and institutional protocol.
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