ASPECTS — how to score?

10-point system in the MCA territory assessed on two axial slices (basal and supraventricular). Subtract 1 point per of the 10 regions with early ischemic signs. ≤ 7 predicts worse functional outcome after thrombolysis.

When to add CT angiography after the initial scan?

Immediately in ischemic stroke with NIHSS ≥ 6, to identify large-vessel occlusion and assess eligibility for mechanical thrombectomy (window up to 24 h per DAWN/DEFUSE-3).

Trauma — when to order?

Canadian CT Head Rule or New Orleans Criteria to select adult patients with mild TBI (GCS 13–15). Children: PECARN.

Report template — CT of skull/brain

When to use

Head CT is the first-line method for suspected acute stroke (rule out hemorrhage before thrombolysis), head trauma, thunderclap headache, decreased level of consciousness and post-surgical follow-up. For acute ischemia, integrate ASPECTS when applicable.

What to evaluate

Acute hemorrhage: epidural, subdural, subarachnoid, intraparenchymal, intraventricular.
Early ischemic signs (hypodensity, loss of cortico-subcortical differentiation, sulcal effacement, ASPECTS).
Mass effect, midline shift, herniation.
Collections, calcifications, focal lesions.
Ventricular system, cisterns and calvaria.

Interactive template

Fill the blanks0/0

Técnica: TEC 1 SC: Realizados cortes axiais sem a injeção do meio de contraste endovenoso. TEC 2 CC: Realizados cortes axiais antes e após a injeção do meio de contraste endovenoso. Análise: - Sistema ventricular: com forma e dimensões conservadas. - Sulcos corticais e cisternas basais: de amplitude preservada. - Parênquima encefálico: com forma e atenuação normais. - Hemorragia intracraniana recente: ausente. - Calota craniana: sem alterações focais evidentes. #### - Realces focais anômalos: ausentes. Comparação: Estudos anteriores não disponíveis para a análise. Conclusão: Exame tomográfico do crânio dentro dos parâmetros da normalidade.

Template in Brazilian Portuguese (clinical reporting language). Adapt to your service protocol. Not medical advice — the physician reviews, edits and signs.

How to use

Replace each [...] with the exam's measurement or descriptor.
Adapt the conclusion to your service protocol before signing.
Use the template as a starting point — not a replacement for physician review.
In Laudos.AI, dictate findings in natural speech and the AI structures text in this format for review.

Related classifications

ASPECTS — CT score for ischemic stroke

Frequently asked

ASPECTS — how to score?: 10-point system in the MCA territory assessed on two axial slices (basal and supraventricular). Subtract 1 point per of the 10 regions with early ischemic signs. ≤ 7 predicts worse functional outcome after thrombolysis.
When to add CT angiography after the initial scan?: Immediately in ischemic stroke with NIHSS ≥ 6, to identify large-vessel occlusion and assess eligibility for mechanical thrombectomy (window up to 24 h per DAWN/DEFUSE-3).
Trauma — when to order?: Canadian CT Head Rule or New Orleans Criteria to select adult patients with mild TBI (GCS 13–15). Children: PECARN.

References

Powers WJ et al., Stroke 2019 (AHA/ASA guideline).
Stiell IG et al., Lancet 2001 (Canadian CT Head Rule).