<!

--
===========================================================================
Copyright (c) 2009, Radiological Society of North America, Inc. (RSNA)
ALL RIGHTS RESERVED

This file is part of the "RSNA Radiology Reporting Templates."

The "RSNA Radiology Reporting Templates" are licensed without charge under
the RSNA's license agreement (the "License"); you may not use this file
except in compliance with the License.
You may obtain a copy of the License at:
http://reportingwiki.rsna.org/index.php?title=File:License.doc
Unless required by applicable law or agreed to in writing, software
distributed under the License is distributed on an "AS IS" BASIS, WITHOUT
WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.
See the License for the specific language governing permissions and
limitations under the License.
===========================================================================
-->
RSNA CCTA TEMPLATE

Clinical Indication: [#] year old [woman |man] with coronary artery disease risk
factors of [hyperlipidemia; hypertension; diabetes; autoimmune disease; prior M
I; prior stroke; smoking history; family history of heart disease] presenting wi
th [exertional angina; atypical chest pain; chronic chest pain; shortness of bre
ath; arm pain; jaw pain; palpitations; ECG changes; prior abnormal single photon
emission computed tomography study; prior abnormal echocardiogram; heart failur
e; cardiomyopathy; pre-surgical assessment] for evaluation of the presence of co
ronary artery disease.
Comparison studies: [type; date]
Imaging Technique: A [#]-slice multidetector computerized tomography coronary an
giogram was obtained using [prospective | retrospective] ECG gating. [{only inse
rt this sentence if retrospective ECG gating was used}ECG tube modulation [*was
used to reduce the radiation exposure | was not used because of arrhythmia| was
not used because of the need for systolic and diastolic imaging]. The coronary C
T angiogram was performed with [#] mL of [type] contrast administered intravenou
sly. Imaging was performed from the level of the [pulmonary artery bifurcation |
carina] to the level of the hemidiaphragms. In order to provide better evaluati
on of the anatomy and disease process, advanced off-line 3-D post-processing tec
hniques, including [multiplanar reconstruction; maximal intensity projections; c
urved reconstructions; and volume rendering] were performed. {If a calcium score
has been performed, the technique and results should also be included in the CT
angiogram report}.
Medication administered in preparation for the examination:
ß- blocker: [[#] mg [type] p.o. x [#] doses]; [[#] mg [type] IV x [#] doses] for h
eart rate/rhythm control
[Calcium channel blocker: [#] mg [type] IV x [#] doses for heart rate/rhythm con
trol]
Nitroglycerin: [* 0.4] mg SL [*spray | tablet] for coronary vasodilation
{Describe any pre-examination steroid preparation or Benadryl administration her
e for contrast allergy}
Vital Signs: Before medication administration, the heart rate was [#] beats per
minute and the blood pressure was [#] mm Hg. Upon discharge, the heart rate was
[#] beats per minute and the blood pressure was [#] mm Hg.
Procedure Complications/ Allergic reactions: [*none].
Radiation Dose: The CT dose index-volume was [#] mGy, and dose length product of
the examination was [#] mGy-cm.
Coronary CT Angiogram Quality: The overall quality of the CT angiographic examin
ation is [excellent| good| fair | poor | nondiagnostic] and is limited by [poor
arterial opacification; misregistration artifacts; patient motion; calcium bloom
ing artifacts; metal artifact; arrhythmia].
Coronary Artery Angiogram Findings:
Stenoses are reported as maximum percentage diameter stenosis.
Stenosis grading is reported using the following scheme:
Normal: no stenosis
Mild: 1-49% stenosis
Moderate: 50-70% stenosis
Severe: >70% stenosis
Occluded
Dominance of the coronary artery system: [*right | left | co-dominant] with [*no
rmal | anomalous] origins and course.
Left Main: The left main is a [*normal | small] caliber vessel which gives rise
to the [* LAD and circumflex arteries | LAD and circumflex arteries as well as a
ramus intermedius artery {if this option is chosen, the qualities of the ramus
intermedius branch need to be reported}]. The left main [has no stenosis | has m
ild stenosis | has moderate stenosis | has severe stenosis | is occluded | is no
nevaluable] with [no | noncalcified | mixed | calcified] plaque. {If present, st
ents should be described by size (if known), type (if known), number, and segmen
tal location. Any relation to the adjacent branch vessel ostium should be descri
bed. In addition, the stent should be described as patent, occluded, or stenosed
. Any in-stent stenosis, fracture, or calcification should also be described}
Left Anterior Descending Artery: The proximal left anterior descending artery an
d first diagonal branch [have no stenosis | have mild stenosis | have moderate s
tenosis | have severe stenosis | are occluded | are nonevaluable] with [no | non
calcified | mixed | calcified] plaque. The mid-distal LAD, D2 and D3 branches [h
ave no stenosis | have mild stenosis | have moderate stenosis | have severe sten
osis | are occluded | are nonevaluable] with [no | noncalcified | mixed | calcif
ied] plaque. [There is a [short | long] [superficial | deep] myocardial bridge
in the [proximal; mid; distal] segment]. {If present, stents should be described
by size (if known), type (if known), number, and segmental location. Any relati
on to the adjacent branch vessel ostium should be described. In addition, the st
ent should be described as patent, occluded, or stenosed. Any in-stent stenosis,
fracture, or calcification should also be described}
[The ramus intermedius branch [has no stenosis| has mild stenosis | has moderate
stenosis | has severe stenosis |is occluded |is nonevaluable] with [no | noncal
cified | mixed | calcified] plaque].]
Left Circumflex Artery: The left circumflex artery and its obtuse marginal [and
left posterior descending artery; and left posterolateral] branches [have no ste
nosis | have mild stenosis | have moderate stenosis | have severe stenosis | are
occluded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaqu
e. {If present, stents should be described by size (if known), type (if known),
number, and segmental location. Any relation to the adjacent branch vessel ostiu
m should be described. In addition, the stent should be described as patent, occ
luded, or stenosed. Any in-stent stenosis, fracture, or calcification should als
o be described}
Right Coronary Artery: The right coronary artery and acute marginal [and right p
osterior descending artery; and right posterolateral] branches [have no stenosis
| have mild stenosis | have moderate stenosis | have severe stenosis | are occl
uded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaque. {I
f present, stents should be described by size (if known), type (if known), numbe
r, and segmental location. Any relation to the adjacent branch vessel ostium sho
uld be described. In addition, the stent should be described as patent, occluded
, or stenosed. Any in-stent stenosis, fracture, or calcification should also be
described}
Cardiac Morphology:
The right atrium is [*normal | dilated]. The right ventricle is [*normal | dilat
ed | hypertrophied]. The left atrium is [*normal | dilated]. The left ventricle
is [*normal | dilated | hypertrophied]. [There are features of [an interatrial s
eptal defect | an interventricular septal defect | an interatrial and interventr
icular septal defect | a patent foramen ovale]. The pericardium is [*normal | th
ickened | calcified] and there is [*no | a small | a moderate | a large] pericar
dial effusion. The aortic valve [* is tricuspid | is congenitally bicuspid | is
functionally bicuspid] with [*normal leaflets | leaflet thickening | leaflet thi
ckening and calcification] [and [*there is no evidence for motion abnormality |
regurgitation | stenosis] {reported only if retrospective ECG gating has been us
ed}]. The mitral valve leaflets are [*normal | thickened | thickened and calcifi
ed] [and [*there is no evidence for motion abnormality | prolapse of the [anteri
or; posterior; anterior and posterior] leaflet | a flail [anterior; posterior; a
nterior and posterior] leaflet | stenosis] {reported only if retrospective ECG g
ating has been used}]. The heart is [*well separated from | abuts] the sternum.
[Cardiac Function {reported only if retrospective ECG gating has been used}
The calculated left ventricular ejection fraction is [#] %, the left ventricular
end-diastolic volume is [#] mL, and the left ventricular end-systolic volume is
[#] mL. There [are no regional wall motion abnormalities | is [hypokinesia | a
kinesia | dyskinesia] of the [basal; mid ; apical; apex] [anterior wall; anterol
ateral wall; anteroseptal wall; lateral wall; inferolateral wall; inferoseptal w
all; septal wall; inferior wall] of the left ventricle.]
[Cardiac Devices and Indwelling Central Venous Lines: {the presence of a pacemak
er, central venous line, etc should be discussed here}]
Extracardiac findings:
The [main; right; left] pulmonary artery is [*normal; enlarged; stenotic]. There
[are | are no] filling defects in the [lobar; segmental; subsegmental] pulmonar
y artery branches consistent with pulmonary arterial embolism. The visualized th
oracic aorta is [*normal | enlarged]. {If the aorta is enlarged, dissected, or t
ransected: size, location, and description should be dictated especially for fin
dings of acute aortic syndromes.} The [*lungs; right upper lobe; right middle l
obe; right lower lobe; left upper lobe; lingual; left lower lobe] [* are normal
| is consolidated | is atelectatic | has a [#] mm nodule | has a calcified granu
loma]. The included portion of the upper abdomen [* is normal | demonstrates a [
small | moderate | large] sized hiatal hernia | [other]].
Impression:
1. [*Normal coronary CTA without evidence for coronary artery stenosis | Abnorma
l coronary CTA with []]. {Describe the important coronary CTA findings here. If
a calcium score was performed, the total score should also be included in the r
eport impression.}
2. [* Normal | Abnormal] global and regional wall motion and function of the LV.
{If abnormal give pertinent findings here.}
[3. {Any additional pertinent cardiac findings.}]
[4. {Any non-cardiac pertinent findings including lung nodule recommendations. I
f a lung nodule is described without known malignancy, a statement of the Fleish
ner Society guidelines for appropriate follow-up should be included in the dicta
tion.}]
Result Communication:
[Dr. [name] | Dr. [name] s assistant [name] | [other] was notified [by telephone |
in person] of the [*study findings | critical result] at [time] on [date] and t
hey acknowledged receipt of the result. {If this was a critical result, the app
ropriate critical result guidelines of your institution should be followed.}]