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Normal Liver MRI Report Template (Dynamic Contrast, LI-RADS)
Normal liver MRI report template with dynamic and hepatobiliary phase contrast in a LI-RADS context: no observations, normal fat and iron, biliary tree, vasculature, spleen and pancreas, with notes on LI-RADS NC, threshold growth and the technical adequacy statement.
EXAMINATION: MRI abdomen (liver protocol) with and without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Hepatocellular carcinoma surveillance in cirrhosis”] COMPARISON: None available. TECHNIQUE: Multiplanar multisequence MR imaging of the liver including axial T2, T2 fat-suppressed, in- and opposed-phase T1, diffusion-weighted imaging with ADC map, and pre-contrast and dynamic post-contrast fat-suppressed T1 images in the late arterial, portal venous and [delayed / transitional] phases, [with a 20-minute hepatobiliary phase,] after the intravenous administration of [x] mL of [gadolinium-based contrast agent]. Technical quality: adequate. FINDINGS: Liver: Normal size and contour. No surface nodularity or lobar redistribution. Homogeneous parenchymal signal on all sequences. No signal loss on opposed-phase imaging to suggest steatosis. No signal loss on in-phase or T2* imaging to suggest iron deposition. Homogeneous enhancement through all phases. No arterial-phase hyperenhancing observation, washout or enhancing capsule. [Homogeneous hepatobiliary phase uptake with no hypointense observation.] No LI-RADS observation. Biliary tree: No intrahepatic or extrahepatic biliary dilatation. Common bile duct measures [x] mm. Normal gallbladder without calculus or wall thickening. Portal and hepatic vasculature: The portal, splenic and superior mesenteric veins are patent with normal antegrade enhancement. No portal vein thrombus or tumor in vein. The hepatic veins and hepatic artery are patent. Spleen: Normal size, measuring [x] cm. No splenic lesion. Portosystemic collaterals: None. No varices, recanalized paraumbilical vein or splenorenal shunt. Pancreas: Normal signal and contour. No mass or ductal dilatation. Adrenal glands: Unremarkable. Kidneys: No solid renal mass. [Simple cysts measuring up to x cm.] Peritoneum: No ascites. Lymph nodes: No enlarged upper abdominal or portacaval lymph nodes. Bones and soft tissues: Unremarkable. IMPRESSION: 1. No LI-RADS observation. No arterial-phase hyperenhancing lesion, washout or threshold growth. Negative for hepatocellular carcinoma by LI-RADS criteria at this examination. 2. No imaging evidence of cirrhosis or portal hypertension. No hepatic steatosis or iron deposition. 3. Normal biliary tree, pancreas and spleen.
Dictation notes
- State the technical adequacy and the phases obtained — LI-RADS is applied only to a technically adequate multiphase study in a patient at risk (cirrhosis, chronic hepatitis B or a prior HCC), and the arterial phase timing (late arterial, with the portal vein enhanced but hepatic veins not) is what a reviewer checks first.
- A “no observation” report has to say it: the surveillance impression is “No LI-RADS observation” or LR-NC when the study is non-diagnostic, not “no focal lesion”, because the referring hepatologist is tracking the category over time.
- Every observation is categorized LR-1 through LR-5, LR-M or LR-TIV by the major features (size, arterial-phase hyperenhancement, nonperipheral washout, enhancing capsule, threshold growth); an LR-3 is a 3-6 month follow-up, LR-5 is a treatment decision without biopsy, and the number drives both.
- Hepatobiliary phase hypointensity is an ancillary feature favoring malignancy, not a major feature — it can upgrade by one category to LR-4 at most, never to LR-5, and washout is assessed on the portal venous phase only when a hepatobiliary agent is used.
- Report steatosis and iron quantitatively when the sequences allow it (proton density fat fraction, R2*) rather than “mild signal loss”; both modify the appearance of any observation and are tracked by the hepatology clinic.
Related references
LI-RADS v2018 category calculator · Bosniak 2019 renal cyst classification
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