What should a normal Computed Tomography (CT) brain report template include?

Normal CT Brain Report Template

A comprehensive normal CT brain report should include technical details, systematic evaluation of all anatomical structures, and a clear conclusion stating the absence of abnormalities. 1

Technical Information

• Patient demographics (name, DOB, medical record number)
• Date and time of examination
• Indication for the study
• CT technique details:
  • Slice thickness (3mm optimal, maximum 5mm) 2
  • Reconstruction interval (1.5mm optimal, maximum 2.5mm) 2
  • Use of contrast (if applicable)
  • Scanner type (minimum 4-detector CT recommended) 2

Systematic Evaluation

Scalp and Skull

• No evidence of scalp hematoma or soft tissue swelling
• No skull fractures
• Normal skull contour and thickness

Extra-axial Spaces

• No epidural hematoma
• No subdural hematoma or collections
• No subarachnoid hemorrhage
• Normal-appearing falx and tentorium

Brain Parenchyma

• No evidence of intraparenchymal hemorrhage
• No hypodensities suggestive of infarction or edema
• No mass lesions or space-occupying lesions
• Normal gray-white matter differentiation
• No midline shift
• No signs of herniation
• Normal basal ganglia and thalami
• Normal brainstem and cerebellum

Ventricular System

• Normal size, shape, and position of lateral ventricles
• Normal third and fourth ventricles
• No hydrocephalus
• No intraventricular hemorrhage

Vascular Structures

• Normal course and caliber of visualized intracranial vessels
• No vascular malformations
• No evidence of vascular injury 3

Paranasal Sinuses and Mastoid Air Cells

• Clear paranasal sinuses
• Well-aerated mastoid air cells
• No fluid levels or mucosal thickening

Orbits and Soft Tissues

• Normal appearance of orbital contents
• Normal appearance of visualized soft tissues

Conclusion

• No acute intracranial abnormality
• No evidence of traumatic brain injury (if applicable)
• No mass effect or midline shift
• Normal ventricular system
• Normal extra-axial spaces

Important Considerations

For Trauma Cases

When reporting CT scans for suspected traumatic brain injury, pay special attention to:

• Presence of scalp injuries 3
• Potential vascular injuries 3
• Fractures (particularly basilar skull fractures) 2
• Mass effect and secondary injuries 3
• Prior or coexisting pathology 3

Standardization Benefits

Using a structured reporting template:

• Ensures consistent and comprehensive evaluation of all relevant structures
• Improves communication with referring physicians 4, 5
• Increases efficiency and reduces the risk of overlooking important findings 4
• Facilitates comparison with previous studies 4
• Provides clarity for clinical decision-making 4

Pitfalls to Avoid

• Failing to document the technical parameters of the scan
• Omitting evaluation of any anatomical region
• Using ambiguous terminology that could be misinterpreted
• Not correlating findings with clinical information when available
• Overlooking subtle abnormalities at the skull base or posterior fossa due to beam-hardening artifacts

This template provides a comprehensive framework for reporting normal CT brain findings while ensuring all critical areas are systematically evaluated to minimize the risk of missing subtle abnormalities that could impact patient outcomes.