CT Brain / Cervical Spine (Trauma) Synoptic Reporting TemplateCT Brain Non-contrast CT from vertex to skull base. Midline shift: No Yes mm towards the Grey-white differentiation: Normal Abnormal Global absence or reduction Acute focal absence or reduction - (site) Chronic focal absence or reduction - (site)Acute infarction: No Yes (site)Cerebral swelling: No Yes Obliteration of basal cisterns Compression of ventricles and/or sulci – (describe)Hydrocephalus: No Yes - (specify degree)Intracranial haemorrhage: No Yes Extradural haemorrhage: (include age, site, size) Subdural haemorrhage: (include age, site, size for each) Cerebral convexity - Falx - Tentorial - Subarachnoid haemorrhage: (include site and amount eg. trace, moderate) Sulcal - Cisternal - Intraventricular haemorrhage: (include amount eg. trace, large) Lateral ventricle(s) - Third ventricle - Fourth ventricle - Intracerebral haemorrhage: (describe the largest if multiple) Site - Dimensions - mm X mm X mm Deep Superficial Additional smaller haemorrhage/s - (relevant details) Contusion or petechial haemorrhage: Isolated - (site) Multiple - (sites) Grey-white interface Corpus callosum Brainstem Skull fracture: No Yes Calvarial fracture: Non-depressed - (site, open/closed) Depressed - (site, displacement, open/closed) Base of skull fracture: Carotid canal or foramen lacerum – (side, details) Petrous temporal bone - (side, morphology, ossicular chain disruption) Other skull fracture Additional findings: (free text) Pneumocephalus – (site) Herniation syndromes - Periventricular hypoattenuation most consistent with chronic small vessel ischaemia. Prominent ventricles and sulci consistent with cerebral atrophy. (free text) CT Cervical Spine Non-contrast CT from skull base to with sagittal reformats. Contrast enhanced (arterial phase) CT from skull base to with sagittal reformats. Alignment: Normal Abnormal – (specify)Prevertebral soft tissues: Normal Swelling – (level, measurement)Difficult to assess in an intubated patient Cervical degenerative disease: None (<25% disc narrowing, no sclerosis/osteophytes/olisthesis)Mild – (25-50% disc narrowing, minimal sclerosis, <2mm osteophytes, <3mm olisthesis)Moderate – (50-75% disc narrowing, moderate sclerosis, 2-4mm osteophytes, 3-5mm olisthesis)Advanced - (75-100% disc narrowing, severe sclerosis, >4mm osteophytes, >5mm olisthesis)Cervical canal: No abnormality identified Abnormal Epidural haematoma suspected – (include site, thickness, extent) Stenosis - (include level, severity and/or AP canal dimension) Other Craniocervical junction: No abnormality identified Abnormal Atlanto-occipital joint (C0-C1) instability: (details including dislocation / subluxation) Atlanto-axial joint (C1-C2) instability: (details including dislocation / subluxation) Occipital condyle fracture: Type 1 - = comminuted fracture with minimal / no displacement (stable) Type 2 - = a basilar skull fracture which extends into the condyle (stable) Type 3 - = avulsed fragment displaced medially from inferomedial aspect (potentially unstable). Atlas (C1) fracture: Minimally displaced fracture - Significantly displaced fracture - Odontoid (C2) fracture: Type 1 - = odontoid tip Type 2 - = base of odontoid Type 3 - = extending into C2 body Other C2 fracture: Vertebral body - Lateral mass - Lamina - Spinous process - Transverse process involving transverse formaen - Transverse process NOT involving transverse formaen - Other findings Sub-axial Cervical Spine (C3-C7): No acute injury identified Injury 1st Significant injury at (specify level eg. ‘C3/4’ or ‘C5’) Compression fracture - (include measurements eg. loss of height) Burst fracture - (include measurements eg. loss of height, retropulsion) Pedicle fracture - Lateral mass - Lamina fracture - Facet injury: (includes fractures and joint disruption, specify side and other relevant details) Non-displaced – Minimally displaced – Subluxation - Dislocation – (include whether ‘perched’ or ‘locked’) Anterior discoligamentous complex: = ALL, disc, PLL No injury suspected Disruption possible or likely Posterior discoligamentous complex: = ligamentum flavum, facet joint capsule, interspinous ligament No injury suspected Disruption possible or likely 2nd Significant injury at (specify level eg. ‘C3/4’ or ‘C5’) Compression fracture - (include measurements eg. loss of height) Burst fracture - (include measurements eg. loss of height, retropulsion) Pedicle fracture - Lateral mass - Lamina fracture - Facet injury: (includes fractures and joint disruption, specify side and other relevant details) Non-displaced – Minimally displaced – Subluxation - Dislocation – (include whether ‘perched’ or ‘locked’) Anterior discoligamentous complex: = ALL, disc, PLL No injury suspected Disruption possible or likely Posterior discoligamentous complex: = ligamentum flavum, facet joint capsule, interspinous ligament No injury suspected Disruption possible or likely 3rd Significant injury: Isolated spinous or transverse process fracture Spinous process fracture - list all levels Transverse process fracture involving transverse formaen - list all levels Transverse process fracture NOT involving transverse formaen - list all levels Additional findings: (free text) Upper thoracic spine injuries – Upper rib fractures - Pneumothorax - Haemothorax – Soft tissue gas - Neural foraminal stenosis – Apical pulmonary emphysema (free text) Equivocal findings: (free text) Comment: (free text) No acute intracranial abnormality No cervical spine fracture or malalignment (free text)