Normal Head CT Report Template (Non-Contrast)
Normal non-contrast head CT report template: parenchyma, ventricles, hemorrhage and skull sections, with first-call wording notes.
EXAMINATION: CT head without intravenous contrast. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the head without intravenous contrast, with coronal and sagittal reformats. FINDINGS: Parenchyma: No acute territorial infarct. Preserved gray-white differentiation. No mass or mass effect. Hemorrhage: No intracranial hemorrhage. Ventricles: Normal size and configuration. No midline shift. Extra-axial spaces: No extra-axial collection. Skull and skull base: No acute fracture. Paranasal sinuses and mastoids: Clear. Orbits: Unremarkable. IMPRESSION: 1. No acute intracranial abnormality.
Dictation notes
- Early infarct signs (loss of insular ribbon, dense MCA) belong in FINDINGS even when the impression stays negative.
- State the absence of midline shift explicitly — it is the first thing the ED reads.
Related references
Frequently asked questions
What sections belong in a normal non-contrast head CT report?
A structured head CT report covers the parenchyma (no acute territorial infarct, preserved gray-white differentiation, no mass or mass effect), hemorrhage, ventricles and midline shift, extra-axial spaces, the skull and skull base, paranasal sinuses and mastoids, and orbits. The normal impression is 'No acute intracranial abnormality.' Explicitly stating the absence of midline shift matters — it is often the first line emergency clinicians read.
What are the early CT signs of ischemic stroke?
Early infarct signs on non-contrast CT include loss of gray-white differentiation, loss of the insular ribbon, obscuration of the lentiform nucleus, subtle sulcal effacement, and a hyperdense artery sign such as a dense MCA. These belong in the FINDINGS section even when the overall impression remains negative, because they can precede a visible hypodense infarct and directly affect thrombolysis and thrombectomy decisions.
Does a normal head CT exclude subarachnoid hemorrhage?
Non-contrast CT is most sensitive for subarachnoid hemorrhage early after onset — very high within the first six hours on modern scanners — and sensitivity falls as blood is diluted and cleared over subsequent days. A normal CT therefore does not fully exclude SAH in a patient presenting late, and lumbar puncture or CT angiography may follow depending on timing and clinical suspicion. The report answers only what the images show.
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