Noncontrast Head CT Reporting System: A Review Sequence for Emergency Findings

REPORTING SYSTEMATICS / NEURORADIOLOGY

A guide to translating a fixed search pattern for hemorrhage, ischemia, mass effect, and osseous structures into a concise, prioritized report.

On emergency head CT, report order should follow clinical risk

Noncontrast head CT is used for a broad range of indications, including trauma, acute neurologic deficit, altered mental status, and headache. The examination is rapid, but a fixed review sequence is required because of time-sensitive findings such as acute hemorrhage, early ischemia, mass effect, and hydrocephalus.

The resident should inspect every anatomic structure while giving first priority to findings that could change management. Any such finding belongs at the top of the impression. The clinical indication, time of symptom onset, trauma mechanism, anticoagulant use, malignancy, and prior surgical history modify the search pattern.

Suggested image-review sequence

1. Technique and coverage. Check patient motion, metal artifact, scan coverage, reconstructions, and prior examinations. Review brain, subdural, and bone windows separately when needed.
2. Extra-axial spaces. Assess for epidural, subdural, and subarachnoid hemorrhage, collections, and symmetry. Carefully inspect hyperdensities along the falx and tentorium.
3. Brain parenchyma. Search for intraparenchymal hemorrhage, focal hypoattenuation, loss of gray-white differentiation, edema, mass, or contusion. Survey both hemispheres comparatively.
4. Basal ganglia, thalami, brainstem, and cerebellum. Assess the deep gray matter and infratentorial structures in a separate pass while accounting for posterior fossa artifact.
5. Ventricles and cisterns. Assess size, symmetry, intraventricular blood, hydrocephalus, patency of the basal cisterns, and the sulci.
6. Mass effect and herniation. Assess midline shift, ventricular compression, sulcal effacement, and signs of herniation.
7. Vascular clues. In the appropriate clinical context, assess for a hyperdense vessel sign and vascular calcifications; however, vascular patency cannot be definitively established on noncontrast CT.
8. Bones and extracranial structures. Review the calvarium, skull base, visualized facial bones, paranasal sinuses, mastoid air cells, orbits, and scalp soft tissues.

Use measured language for acute ischemia

The primary role of noncontrast CT is to assess for acute hemorrhage and evident early ischemic changes. Findings such as loss of gray-white differentiation, sulcal effacement, or focal hypoattenuation should be interpreted together with symptom timing and vascular territory. A normal noncontrast CT early after symptom onset does not exclude acute ischemia.

Scores such as ASPECTS should be used within an appropriate acute stroke protocol and with proper technique and training. When a score is reported, the hemisphere and assessment conditions should be clear; the score should not replace a free-text description of the anatomic findings.

Integrate osseous and soft-tissue findings in trauma reports

For trauma indications, the review should not stop after searching for hemorrhage. Assess for calvarial and skull-base fractures, their relationship to sutures, pneumocephalus, scalp hematoma, and visualized facial bones. Suspected fractures should be confirmed on bone windows and prioritized in the impression together with adjacent intracranial findings.

When postoperative changes, craniotomy defects, drains, or shunts are present, their course and associated complications should be addressed separately. Prior imaging is critical for distinguishing expected postoperative appearance from a new complication.

Noncontrast head CT report template framework

The template can be expanded with acute stroke, trauma, or follow-up sub-blocks according to the indication:

Common mistakes

• Failing to reassess an examination that appears normal on brain windows using bone and subdural windows.
• Missing a small subdural hemorrhage as a hyperdense line adjacent to the calvarium.
• Reviewing the posterior fossa only superficially because of beam-hardening artifact.
• Failing to state midline shift or basal cistern effacement in the impression.
• Describing chronic microvascular changes using language of acute ischemia.
• Making a definitive statement that excludes acute ischemia, particularly while ignoring CT limitations early after symptom onset.
• Failing to include the calvarium, skull base, and scalp soft tissues in a trauma report.

Urgency and uncertainty in the impression

Acute intracranial hemorrhage, mass effect, hydrocephalus, or herniation should be stated clearly in the first item. The hemorrhage type, side, location, approximate size, and associated mass effect are important for clinical management. Critical findings should be communicated directly according to institutional procedures, and the communication should be documented.

When no acute abnormality is identified, the impression should be framed according to the indication. Rather than writing “normal head CT,” a statement addressing the important assessed categories—such as no acute intracranial hemorrhage or significant mass effect—is more informative.

Quick pre-sign-off check

Were the extra-axial spaces and brain parenchyma surveyed separately for hemorrhage? Were gray-white differentiation and the deep gray matter assessed? Were the ventricles, basal cisterns, and midline checked? Were bone windows, sinuses, mastoids, and scalp reviewed? Does the first item of the impression clearly communicate any time-sensitive finding?

Sources

1. ACR Practice Parameter for Communication of Diagnostic Imaging Findings (Revised 2025) — Core report components, the impression section, and principles for nonroutine communication. Source (se abre en una pestaña nueva)
2. RSNA RadReport Reporting Templates — A resource for standardized, consistent, and comprehensive reporting templates. Source (se abre en una pestaña nueva)
3. ESR paper on structured reporting in radiology—update 2023 — Current framework and implementation principles for structured reporting. Source (se abre en una pestaña nueva)
4. Structured reporting in radiology: a systematic review — A systematic assessment of the evidence on structured reporting. Source (se abre en una pestaña nueva)
5. ACR–ASNR–SPR Practice Parameter for the Performance of Computed Tomography (CT) of the Head — Performance, scope, and documentation of head CT. Source (se abre en una pestaña nueva)
6. ACR–ASNR–SPR Practice Parameter for CT in the Evaluation and Classification of Traumatic Brain Injury — CT evaluation framework for traumatic brain injury.