MRI Report Template

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					                                     MRI Report Template

History:
Relevant clinical history – should include signs/symptoms as well as clinical questions. Becomes
part of a medical and legal record, so do not include anything that is speculative or not definite.
Do include enough so that someone reading it a year later knows exactly what was up.

Technique:
Imaging was performed at 1 or 1.5 Tesla using the body/body array/knee etc. coil. Sequences
include: axial T1-weighted spin echo, sagittal inversion recovery-turbo spin echo, and pre and
post gadolinium fat-saturated T1-weighted spoiled gradient echo images, from the dome of the
diaphragm through the iliac crests (and the like).

   (While a phrase as “routine knee protocol” saves time, it does not help you learn the protocol
    and offers no information to anyone trying to determine the adequacy of the exam.)

Findings:
 Discuss relevant QC issues i.e. examination was directed toward evaluation of the biliary
   tree; images are markedly limited by patient motion; the right iliac vein is almost completely
   obscured by susceptibility artifact from the patient’s hip prosthesis, limiting assessment for
   intraluminal thrombus in this region.
 Concentrate on descriptive terms – Basically, what you would be telling the attending over
   the phone, if you were not sure what you were looking at.
 Size of lesion, # of lesions, well or poorly defined, low/intermediate/high T1 signal intensity;
   low/intermediate/high T2 signal intensity; non-enhancing/peripherally homogeneously
   enhancing lesion in the anterior segment of the right hepatic lobe etc.
 T1 and T2 signal intensity (both!) are the sine qua non for describing and characterizing a
   lesion by MRI.
 Pertinent positives and negatives.
 Think of the clinician reading the report – your description and pertinent comments should
   help them walk through the differential in their mind or convince them of your thesis.
 Corresponds to the finding on the June 23, 1994 CT scan (if you have the CT in front of you).
 Conclusions as to what is going on and recommendations DO NOT belong here (exception
   the ultra-obvious or things you want people to ignore, e.g., small uterine leiomyome noted).

Impression:
Recap brief summary of findings and – now FINALLY – offer your suggested conclusions as to
the diagnoses. Offer any technical caveats or recommendations for additional imaging for follow-
up. If the patient is coming back for additional sequences, be specific as to what is needed – since
you may not be the one on, (e.g., “the patient should return for an additional set of delayed post-
gadolinium imaged through the kidneys”). If the patient had a contrast reaction, be sure to
reiterate it in the Impression.
Knee MRI– Report Template 9/96

History:
Must include symptom, as well as pertinent clinical history and what we are being asked to r/o,
e.g., medial knee pain x 3 months after hitting knee. R/O medial meniscal tear, meniscal cyst, or
loose body.

Technique:
Imaging was performed at 1 (or 1.5) Tesla* using the knee coil. Sequences include sagittal and
(coronal) dual echo T2-weighted conventional spin echo images, sagittal inversion recovery.

MRI of the knee without contrast: Sequences include axial, sagittal, and coronal proton density
and T2-weighted spin echo and sagittal inversion recovery T2-weighted turbo spin echo images
through the right/left knee.

   A moderate sized joint effusion is present, together with a small Baker’s cyst. A medial plica
    is present, without MR evidence of thickening.
   In the medial compartment, the meniscus is within normal limits in signal intensity and
    morphology. Cartilage is grossly preserved. No subchondral marrow edema is identified.
   In the lateral compartment, there is a horizontal tear of the anterior horn of the lateral
    meniscus, surfacing inferiorly (study 3, image 18). There is mild cartilage irregularity. Focal
    marrow edema is present in the subchondral portion of the proximal tibia anteriorly,
    subjacent to the torn meniscus. A small osteophyte arises from the proximal tibia anteriorly.
   The anterior cruciate ligament is intact, but mildly attenuated. There is mild diffuse
    thickening of an otherwise intact medial collateral ligament. The posterior cruciate and lateral
    collateral ligaments are intact, within normal limits in signal intensity and morphology.
   In the patellofemoral compartment, there is thinning of the medial facet articular cartilage and
    a small subchondral cyst is present underlying the medial facet. Lateral facet and femoral
    trochlear cartilage is grossly preserved.
   The quadriceps and patellar tendons are intact, within normal limits in signal intensity and
    morphology. The patellar retinacula are intact. A small amount of subcutaneous edema is
    present anterior to the patellar tendon.

Impression:
   1. Anterior horn, lateral meniscus – horizontal tear surfacing inferiorly. Subjacent narrow
      edema. Mild lateral compartment degenerative changes.
   2. ACL – intact, but mildly attenuated.
   3. Medial patellar facet cartilage irregularity and subchondral cyst, consistent with grade IV
      chondromalacia patellae.
   4. Mild diffuse thickening of otherwise intact MCL, consistent with remote healed sprain.
   5. No evidence of medial meniscal tear or meniscal cyst.
   6. No intra-articular loose body detected by MRI. Correlation with (outside) x-ray is
      recommended to assess for small-calcified loose bodies.
Shoulder MRI

History:
Right/left shoulder pain. Rule-out (rotator cuff and/or labral tear). Other pertinent symptoms and
history.

Technique:
Images performed at 1 (1.5) Tesla using the (large flexible or shoulder) coil. Sequences include
coronal, sagittal, and axial dual echo T2-weighted conventional spin echo and coronal inversion
recovery – T2-weighted turbo spin echo images through the (right/left) shoulder.

Findings:
 Compared with the (right/left) shoulder MRI of (date) no significant change is detected.

   The supraspinatus, infraspinatus, teres minor, and subscapularis muscles and tendons are
    intact, within normal limits in signal intensity and morphology. The arcomino-clavicular joint
    is within normal limits. There is a type (I/II/III) acromion. The acromin-clavicular ligament is
    normal. No fluid or edema is identified in the subacromial-subdeltoid bursa.

   No evidence of anterior or superior labral teas is identified. There is a type 1 capsule
    insertion. Gleno-humeral cartilage is preserved.

   No evidence of superior labral tear is detected. The biceps anchor is intact. The biceps tendon
    is well seated within the intertubercular groove.

   No bone contusion is detected. Scattered erythropoeitic marrow is present. A small
    subchondral cyst underlies the infraspinatus tendon insertion.

   No masses are detected along the course of the suprascapular nerve, within the spinoglenoid
    notch or within the quadrilateral space.

   There is minimal fluid within the joint, within the physiologic limits.

Impression:
MR examination of (right/left) shoulder within normal limits. Correlation without outside plain
films is recommended to assess for mineralization and small calcifications about the joint.

Additional Phrases:
 There is high proton density/low T2 signal within the distal supraspinatus tendon, consistent
  with focal/extensive tendon degeneration (study #, image #).
 There is a (--mm) focus of high proton density/high T2 signal in the distal supraspinatus
  tendon, extending to the (articular/bursal) surface only, consistent with a focal/extensive
  partial tear.
 There is a focus of high proton density/high T2 signal in the distal supraspinatus tendon,
  consistent with a (small/moderate-sized/large) complete tear of the (distal most or see infra)
    supraspinatus tendon (--mm proximal to the distal insertion), (with/without) significant
    tendon retraction. The tear measures –mm in the coronal plane and –mm in the sagittal plane.
    (The supraspinatus muscle itself is normal in signal intensity and morphology, without
    evidence of fatty infiltration or atrophy; or there is minimal/moderate/extensive fatty
    infiltration and/or atrophy of the supraspinatus muscle.)
   There is AC joint hypertrophy, which deforms (extends to, but does not deform) the surface
    of the supraspinatus muscle.
   Minimal fluid is present within the AC joint.
   There is a small/moderate-sized/large spur arising from the distal acromion and/or distal
    clavicle, which deforms (extends to, but does not deform) the surface of the supraspinatus
    muscle.
   There is slight/considerable thickening of the coraco-acrominal ligament.
   There is blunting of and/or degenerative signal within the anterior labrum, without frank
    tear.
   There is a high proton density cleft within the anterior labrum, raising the question of a
    labral tear. → in Conclusion: Ditto. If clinically indicated, MR arthrography could help to
    further assess this finding.
   There is high T2 signal extending into the substance of/between the fibrous labrum and bony
    glenoid, most likely representing a labral tear (avulsion if between labrum and bone).
   High T2 signal at the base of the labrum in the antero-superior portion of the joint most likely
    reflects the presence of a normal variant sublabral foramen.
   There is intersubstance high protone density signal in the intraarticular/intertubercular portion
    of the biceps tendon, consistent with tendon degeneration.
   There is (intersubstance high T2 signal in or interruption of) the intraarticular/intertubercular
    portion of the biceps tendon, consistent with intrasubstance partial tear or tear).
   There is (patchy/diffuse) low proton density/high T2 signal within the metaphyseal and
    diaphyseal marrow space of the humerus. → in Conclusion: Ditto. This can be seen in the
    setting of anemia and/or smoking. Differential diagnosis includes other infiltrative processes.
    Clinical correlation is recommended.
   Note is made of several small (< 1 cm) axial lymph nodes, not enlarged by radiographic
    criteria.
   There is evidence of complete (proximal/mid-substance/distal) tear of the ACL, with focal
    interruption of the fibers and associated hemorrhage and edema (“pseudomass”) (study #,
    image #). In addition, there is edema in the subchondral portion of the lateral femoral condyle
    anteriorly (in the region of the lateral terminal sulcus) and in the posterolateral portion of the
    proximal tibia.
   There is slight thickening of proximal MCL, consistent with remote, healed tear.
   There is loculated fluid (where – study #, image #) consistent with a ganglion.
   There is focal high proton density/low T2 signal in the proximal patellar tendon (study #,
    image #), consistent with tendon degeneration.
Elbow MRI

History:
Symptoms and pertinent clinical history.

Technique:
Imaging was performed 1 (1.5) Tesla using the large flexible coil. Sequences include axial T2-
weighted dual echo conventional spin echo and inversion recovery – T2-weighted turbo spin
echo; coronal T2-weighted dual echo conventional spin echo; and sagittal T1-weighted
conventional spin echo and inversion recovery T2-weighted turbo spin echo images through the
(right/left) elbow.

Findings:
The lateral collateral and medial collateral ligaments are intact, within normal limits in signal
intensity and morphology. The common flexor and common extensor tendons are intact, within
normal limits in signal intensity and morphology. The biceps tendon, triceps tendon, brachialis
and brachioradialis tendons are within normal limits. Remaining muscles and tendons about the
elbow joint are intact.

There is minimal fluid within the elbow joint, within physiologic limits. Hyaline cartilage is
preserved. No bone marrow edema is identified.

Visualized portions of the ulnar and radial nerves, including the deep branch of the radial nerve,
are within normal limits. No masses or spurs are detected about the cubital tunnel. The supinator
muscle is unremarkable.

Impression:
MR examination of the (right/left) elbow within normal limits. If clinical concern for small bony
fragments within the joint remains high, correlation with x-ray (not immediately available to us)
and, if indicated, CT scan would help to further assess this. Correlation with outside x-rays is
also recommended to assess for small spurs or calcifications about the joint.

Additional phrases:
 There is focal high proton density/low T2 within the proximal portion of the lateral
  collateral ligament consistent with focal degeneration.
 There is focal high proton density/low T2 within the proximal portion of the common
  extensor tendon consistent with focal tendon degeneration.
 There is edema within the lateral epicondyle. → in Conclusion: Ditto. This is a nonspecific
  finding, but can be seen in the setting of lateral epicondylitis.
 No normal distal biceps tendon insertion is identified. The distal tendon is retracted and
  wavy. The gap between the distal tendon and the insertion measures -- cm. There is high
  proton density/high T2 signal within the biceps muscle at the level of the ____, consistent
  with hemorrhage and/or edema. → in Conclusion: Findings consistent with distal biceps
  tendon rupture, with -- cm gap between distal tendon and tendon insertion site.
   The ulnar nerve is prominent and of increased T2 signal, at level of (e.g., the epicondyle,
    cubital tunnel etc.) → in Conclusion: Ditto. In the appropriate clinical setting, this would be
    consistent with ulnar nerve neuritis.
Hip Examination

History:
Pain in right/left/both hips. Other pertinent history.

Technique:
Imaging was performed at 1 (1.5) Tesla using the body array coil. Sequences include coronal and
axial T1-weighted conventional spin echo and inversion recovery – T2-weighted turbo spin echo
images through both hips.

Findings:
Images are directed toward evaluation of the hip joints. No fracture or dislocation is detected
involving either hip joint. No obvious degenerative changes are identified. No marrow edema is
identified about the hip. There is minimal fluid in (right/left/both) hips, within physiologic limits,
without frank joint effusion. Visualized portions of the muscles and soft tissues about the pelvic
girdle are within normal limits in signal intensity and morphology. No edema is identified about
the greater trochanter to suggest trochanteric bursitis. The pyriformis muscles are symmetric.

Examination of the pelvic parenchymal structures is limited. (e.g., if applicable: allowing for this,
there is a 2.5 cm rounded, well-circumscribed structure arising from the right ovary, presumably
representing an ovarian cyst.)

Impression:
1. MR examination of both hips within normal limits. (No evidence of proximal femoral
   fracture.)
2. -- cm (right/left) ovarian cyst. Follow-up examination at a different point in the patient’s
   menstrual cycle (e.g., 6 weeks) is recommended to confirm resolution. Follow-up by
   ultrasound would be possible.
Hip Arthrogram

History:
Right/left hop pain, ?labral tear. Pertinent clinical and previous surgical history.

Technique:
Following instillation of dilute gadolinium into the R/L hip, imaging was performed at 1.5 Tesla,
using the large flexible coil (please see separate report of the procedure). Sequences include
axial, sagittal, and coronal fat saturated T1-weighted conventional spin echo; fat saturated 3D
T1-weighted gradient echo images acquired in the axial plane; coronal T1-weighted conventional
spin echo and inversion recovery T2-weighted turbo spin echo images, through the (right/left)
hip.

Findings:
Examination is directed toward evaluation of the intra-articular structures of the right/left hip.
The acetabular labrum is well seen, within normal limits in signal intensity and morphology. No
extra-articular collections of gadolinium are identified. No macroscopic cartilage defects are
detected. A small rounded low signal focus seen in the non-dependent portion of the joint most
likely represents a small amount of air. A small amount of gadolinium in the soft tissues anterior
to the joint is thought to relate to the arthrographic procedure.

Impression:
No evidence of labral tear or macroscopic articular cartilage defect. Correlation with (outside)
plain films is recommended to assess for small bony fragments about the joint.

Additional phrases:
 Linear high signal extends between the superior/anterior/posterior labrum and the bony
  acetabulum (study #, image #) → in Conclusion: Ditto, consistent with
  anterior/superior/posterior labral avulsion.
 A small collection of gadolinium is seen immediately anterior to the joint space, at the base
  of the labrum, consistent with a small extra-articular synovial cyst.
 Linear high signal is seen extending into the substance of the superior/anterior/posterior
  labrum and the bony acetabulum (study #, image #) → in Conclusion: Ditto, consistent with
  anterior/superior/posterior intrasubstance labral tear.
 There is slight fraying of the anterior/superior/posterior labrum.
 Minimal cartilage irregularity (give location). Focal cartilage defect (give size and location).
Shoulder Arthrogram

History:
Right/left shoulder pain. Other pertinent clinical history.

Technique:
Imaging was performed at 1.5 Tesla using the (large flexible/shoulder) coil, following instillation
of dilute gadolinium into the joint – please see separate report from the arthrographic procedure.
Sequences include axial, sagittal, and coronal fat saturated T1-weighted conventional spin echo
images through the right/left shoulder as well as coronal T1-weighted conventional spin echo and
coronal inversion recovery T2-weighted turbo spin echo images.

Findings:
Examination is directed toward evaluation of the intra-articular structures of the glenohumeral
joint. The joint is (well/moderately well) distended. No gadolinium contrast material is detected
outside the confines of the joint, to suggest the presence of a rotator cuff tear. No contrast is
identified extending through or beneath the labrum to suggest the presence of a labral tear. No
macroscopic cartilage defects are identified. No Hill-Sachs lesion is detected. No obvious bone
marrow edema is identified.

Impression:
MR arthrogram examination of the (right/left) shoulder within normal limits, without evidence of
rotator cuff or labral tear.
Ankle Examination

History:
Right/left ankle pain. Other pertinent clinical history, including trauma or previous surgery and
activities.

Technique:
Imaging was performed at 1(1.5) Tesla using the extremity (head/flexible) coil. Sequences
include axial dual echo conventional spin echo, coronal dual echo conventional spin echo,
sagittal T1-weighted conventional spin echo and sagittal inversion recovery – T2-weighted turbo
echo images of the right/left ankle.

Findings:
No fracture, dislocation, or gross degenerative change is detected about the ankle joint. There is
minimal fluid within the joint, within physiologic limits. No marrow edema is detected about the
joint. There is no evidence of osteochondral defect.

Visualized portions of the tendons and muscles crossing the ankle joint are within normal limits
in signal intensity and morphology. No evidence of tendon tear or degeneration or of
tenosynovitis is detected. The tibiofibular, talofibular ligaments, and the calcaneofibular
ligaments are well seen and are intact.

No masses are detected within the tarsal tunnel. The sinus tarsi is within normal limits in signal
intensity and morphology. The origin of the plantar fascia is within normal limits.

Impression:
MR examination of the (right/left) ankle within normal limits.
Wrist Examination

History:
Right/left wrist pain. Other symptoms in pertinent clinical history.

Technique:
Imaging was performed at 1 (1.5) Tesla using the small flexible coil. Sequences include axial
dual echo T2-weighted conventional spin echo; coronal T1-weighted conventional spin echo and
inversion recovery – T2-weighted turbo spin echo; and 2D T2 star weighted gradient echo
images through the (right/left) wrist. Sagittal T1-weighted conventional spin echo images were
also obtained.

Findings:
No fracture, dislocation or degenerative change is detected about the (right/left) wrist. The carpal
bones are within normal limits in signal intensity and morphology. The triangular fibrocartilage
is intact. The carpal tunnel is within normal limits, without evidence of convex bowing of the
flexor retinaculum, abnormally increased signal of the median nerve, or synovitis or mass lesion
within the carpal tunnel. No joint effusions or ganglia are detected about the wrist. Visualized
portions of the tendons crossing the wrist are within the normal limits, without evidence of
tendon rupture, degeneration, or tenosynovitis.

Impression:
MR examination of the (right/left) wrist within normal limits.
Lumbar Spine MRI

History:
Low back pain +/- right/left sciatica. Other pertinent symptoms and history, including previous
surgery.

Technique:
Imaging was performed at 1 (1.5) Tesla using the spine array coil. Sequences include sagittal T1-
weighted conventional spin echo, sagittal T2-weighted turbo spin echo images through the
lumbar and sacral spine and axial T1-weighted conventional spin echo and axial T2-weighted
turbo spin echo images through the L3-L5 (include any additional levels) disc levels.
(Administration of approximately 15 cc of ionic intravenous gadolinium contrast material was
uneventful.)

Findings:
The conus medullaris lies at the – level. Visualized portions of the spinal cord are within normal
limits in signal intensity.

The (specify) lower thoracic and upper lumbar discs are included on the sagittal images only and
are within normal limits.

Lumbar lordosis is preserved. No spondylolisthesis id identified. Vertebral bodies are within
normal limits in signal intensity and morphology, without evidence of vertebral body
compression.

At the L3/4 level, the disc is within normal limits in signal intensity and height, without evidence
of disc bulge or protrusion. No central canal or neural foraminal stenosis is identified.

At the L4/5 level, the disc is within normal limits in signal intensity and height, without evidence
of disc bulge or protrusion. No central canal or neural foraminal stenosis is identified.

At the L5/S1 level, the disc is within normal limits in signal intensity and height, without
evidence of disc bulge or protrusion. No central canal or neural foraminal stenosis is identified.

Remember to check for occult pathology: aortic aneurysm, renal mass, and pelvic mass.

Impression:
MR examination of the lumbar spine within normal limits.

Additional phrases:

There is a (size, configuration) right paracentral disc protrusion, impinging on the right L4 nerve
root.