Normal CT Pulmonary Angiogram (CTPA) Report Template
Normal CT pulmonary angiogram report template: no filling defect to the subsegmental level, right heart strain assessment, and alternative-diagnosis wording.
EXAMINATION: CT pulmonary angiogram. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the chest following intravenous contrast administration timed for the pulmonary arteries, with multiplanar reformats. FINDINGS: Pulmonary arteries: Contrast opacification is adequate for diagnosis. No filling defect in the main, lobar, segmental or subsegmental pulmonary arteries to the subsegmental level. The main pulmonary artery is normal in caliber, measuring [x] cm. Right heart: No CT evidence of right heart strain. The RV/LV ratio is less than 1. No interventricular septal bowing or contrast reflux into the hepatic veins. Lungs: Clear. No focal consolidation, suspicious nodule or mass. Pleura: No pleural effusion or pneumothorax. Heart and mediastinum: Normal heart size. No pericardial effusion. No lymphadenopathy by size criteria. Thoracic aorta: Normal caliber. Bones and chest wall: No acute osseous abnormality. Upper abdomen: Grossly unremarkable on included images. IMPRESSION: 1. No pulmonary embolism to the subsegmental level. 2. No CT evidence of right heart strain.
Dictation notes
- State the diagnostic quality of the study first — a suboptimally opacified CTPA excludes only central PE, and the impression must say so.
- When PE is present, the RV/LV ratio and septal bowing drive triage to the PERT pathway; keep the strain line in every template so it is never forgotten.
- A negative CTPA still owes the clinician an answer — name the alternative diagnosis (pneumonia, effusion, rib fracture) when one is visible.
Related references
Fleischner pulmonary nodule follow-up
Frequently asked questions
What does a normal CTPA report include?
A CT pulmonary angiogram report first states that contrast opacification is adequate for diagnosis, then that no filling defect is present in the main, lobar, segmental or subsegmental pulmonary arteries. It addresses right heart strain, main pulmonary artery caliber, and the lungs, pleura, mediastinum, aorta, bones and imaged upper abdomen. The normal impression is 'No pulmonary embolism to the subsegmental level' plus 'No CT evidence of right heart strain.'
What are the CT signs of right heart strain in pulmonary embolism?
CT signs of right heart strain include a right-to-left ventricular diameter ratio of 1 or more, bowing of the interventricular septum toward the left ventricle, and contrast reflux into the hepatic veins. When pulmonary embolism is present these findings drive triage — including activation of a pulmonary embolism response pathway — so the strain assessment belongs in every CTPA report, stated explicitly even when negative.
How should a suboptimal CTPA be reported?
The report should state the diagnostic quality of the study first. A suboptimally opacified CTPA reliably excludes only central pulmonary embolism, and the impression must say so rather than issuing an unqualified negative. A negative study also owes the clinician an answer to the presenting symptoms: when an alternative diagnosis such as pneumonia, pleural effusion or a rib fracture is visible, naming it belongs in the impression.
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