Cranial CT Report Composer
Study
Clinical data (required)
Non-enhanced
Contrast-enhanced
Comparison
None
Non-enhanced cranial CT scan
Contrast-enhanced cranial CT scan
Cranial CT angiogram
Date
Infarct
Infarct present
Age
Acute
Subacute
Chronic
Location
Loss of grey-to-white matter differentiation
Hemorrhage
Hyperdense collection present
Location
Size (cm)
×
×
—
cc (A × B × C × 0.524)
Age
Acute
Subacute
Chronic
Perilesional hypodensity (vasogenic edema)
Intraventricular extension
Lateral ventricle
Left
Right
Bilateral
Third ventricle
Fourth ventricle
Resultant ventricular dilatation
none
mild
moderate
marked
Mass effect
Effacement of adjacent cortical sulci
Compression of
mild
moderate
marked
Midline shift
Rightward
Leftward
Uncal herniation
Right
Left
Enhancement
No undue leptomeningeal or parenchymal enhancement
Old lacunar infarcts and white matter
Old lacunar infarcts
none
single
Few
Several
Multiple
Chronic microvascular white matter ischemic changes
none
Mild
Moderate
Severe
Normal structures
Midline structures in place
Brainstem and cerebellum unremarkable
Sulci, ventricles and cisterns
Unremarkable
Mildly prominent (cerebral)
Mildly prominent (cerebral and cerebellar)
Sella
Partially empty
Unremarkable
Atherosclerosis
Atherosclerotic vessel disease
Severity
Mild
Moderate
Extensive
Internal carotid arteries
bilateral
left
right
Vertebral arteries
bilateral
left
right
Sinuses, petromastoids, orbits and bones
Unremarkable
Sinusitis
Mastoiditis
Type
Acute
Chronic
Side
Aphakia / pseudophakia
Side
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