{"id":"699fbd0defd4f1d917502b60","name":"CT Head Without Contrast","slug":"ct-head-without-contrast","description":"Structured template for non-contrast CT imaging of the brain, optimized for rapid assessment of acute intracranial pathology","category":{"modality":"CT","system":"CNS"},"tags":["brain","head","non-contrast","acute","hemorrhage screening","stroke protocol"],"sections":{"title":{"defaultText":"CT Head Without Contrast","aiInstructions":"Use the study type as stated in the source report. Standard title format for non-contrast head CT studies."},"clinicalHistory":{"defaultText":"[Patient-specific — populated at report time]","aiInstructions":"Ask the user for: patient age, sex, presenting complaint, relevant clinical history, and reason for the exam. This section contextualizes the entire report. Always include it."},"comparison":{"defaultText":"No prior studies available for comparison.","aiInstructions":"If prior imaging is mentioned in the source report, document the specific prior study type and date. Otherwise use default text."},"technique":{"defaultText":"Non-contrast CT imaging of the head was performed.","aiInstructions":"Describe imaging technique based on source report. Include slice thickness, reconstruction parameters, and contrast administration status. For this study, emphasize non-contrast technique."},"findings":{"defaultText":"The brain parenchyma is unremarkable. No acute intracranial abnormality identified.","aiInstructions":"Organize findings by anatomical structure. Document each structure systematically from superior to inferior. Include only findings explicitly mentioned in source report.","fields":[{"name":"Brain Parenchyma","defaultText":"The cerebral hemispheres are symmetric with no focal areas of abnormal attenuation. Gray-white matter differentiation is preserved.","aiInstructions":"Assess for acute ischemia, contusions, or edema. Document any areas of abnormal density. If source mentions normal parenchyma, use default text."},{"name":"Intracranial Hemorrhage","defaultText":"No intracranial hemorrhage is identified.","aiInstructions":"Specifically assess for acute, subacute, or chronic bleeding in epidural, subdural, subarachnoid, intraparenchymal, or intraventricular locations. This is critical for non-contrast head CT. If source explicitly states absence of hemorrhage, use default text."},{"name":"Mass or Neoplasm","defaultText":"No intracranial mass is identified.","aiInstructions":"Assess for any focal mass lesion, tumor, or space-occupying lesion. Document size, location, and effect on adjacent structures if present. If source states absence of mass, use default text."},{"name":"Ventricular System","defaultText":"The lateral ventricles are normal in size and configuration. The third and fourth ventricles are patent and unremarkable.","aiInstructions":"Assess ventricular size, symmetry, and patency. Document any evidence of hydrocephalus or obstruction. Include midline shift assessment if relevant."},{"name":"Sulci and Cisterns","defaultText":"The cortical sulci and basal cisterns are preserved and unremarkable.","aiInstructions":"Assess for sulcal effacement suggesting edema, or cisternal effacement suggesting mass effect or increased intracranial pressure."},{"name":"Midline Structures","defaultText":"The midline structures are normal without evidence of shift.","aiInstructions":"Assess pineal gland, septum pellucidum, and corpus callosum. Document any midline shift or distortion."},{"name":"Skull and Calvarium","defaultText":"The skull is intact without fracture.","aiInstructions":"Assess for fractures, lytic or sclerotic lesions, or other bony abnormalities. Document location and displacement if fracture present."},{"name":"Sinuses and Mastoids","defaultText":"The paranasal sinuses and mastoid air cells are clear and well-aerated.","aiInstructions":"Assess for sinusitis, opacification, or mastoiditis. Document air-fluid levels or mucosal thickening if present."},{"name":"Extra-axial Spaces","defaultText":"No subdural, epidural, or subarachnoid fluid collections are identified.","aiInstructions":"Specifically assess for subdural hematoma, epidural hematoma, and subarachnoid hemorrhage. Document location, size, and mass effect if present."}]},"impression":{"defaultText":"Non-contrast CT of the head is normal. No acute intracranial hemorrhage, mass, or other significant abnormality.","aiInstructions":"Synthesize key findings into a concise clinical summary. State whether study is normal or abnormal. List significant findings in order of clinical importance. If source report indicates normal study with no hemorrhage or mass, use default text. If abnormalities are present, replace with specific findings and clinical significance."}},"aiUsageInstructions":{"summary":"Use this template to generate a complete CT Head Without Contrast radiology report.","steps":["1. Collect patient clinical history from the user (age, sex, clinical indication).","2. Confirm whether prior studies are available for comparison.","3. For the Technique section, use defaultText or adapt based on actual acquisition parameters.","4. For each field in sections.findings.fields: ask the user for the finding or infer from clinical context. Use defaultText if the structure is normal.","5. Generate the Impression by summarizing the most significant findings from step 4.","6. Use the aiInstructions for each section to guide the depth and format of the content.","7. Maintain formal radiology report language throughout. Passive voice preferred.","8. If any finding is abnormal, quantify it with measurements and describe its imaging characteristics."],"language":"Formal radiology report language. Passive voice preferred. Avoid first-person pronouns.","format":"Numbered impression list. Prose findings paragraphs or structured field-by-field format both acceptable.","units":"Report measurements in centimeters (cm) for masses, millimeters (mm) for small structures."},"meta":{"canonicalUrl":"https://radiluxreports.com/templates/ct-head-without-contrast","claudeApiUrl":"https://radiluxreports.com/templates/api/claude/ct-head-without-contrast","useInDashboardUrl":"https://radiluxreports.com/?templateId=699fbd0defd4f1d917502b60","apiUrl":"https://radiluxreports.com/templates/api/ct-head-without-contrast","updatedAt":"2026-03-01T00:12:10.061Z","license":"Free for clinical and educational use. Attribution appreciated."}}