Structured Reporting of Acute Ischemic Stroke – Consensus-Based Reporting Templates for Non-Contrast Cranial Computed Tomography, CT Angiography, and CT Perfusion

Key words

structured reporting - ischemic stroke - computed tomography

Structured reporting is an essential step in establishing quality standards in diagnostic radiology. This type of reporting uses standardized templates tailored to specific medical issues. It differs from the free-form texts that are currently most commonly used for reporting in the clinical routine.

Structured reporting provides a greater degree of completeness and thus better report quality [1] [2] [3] [4] [5]. According to multiple studies, most clinical referring physicians prefer structured reporting to free-form texts [6] [7] [8]. The primary goal of a structured reporting template is to provide a high-quality radiology report for a specific radiological examination in accordance with the current state of knowledge. Structured reporting templates are typically created in consensus with specialist support provided by radiology and clinical experts.

Structured reporting complements imaging schemes that are already established in the determination of the further clinical approach, such as the Alberta Stroke Program Early Computed Tomography (CT) Score (ASPECTS), which is used in neuroradiology for stroke treatment, or the Response Assessment in Neuro-Oncology (RANO) criteria, which are used for evaluating the treatment of brain tumors [9] [10]. They are an important component of evidence-based medicine, which requires guideline-based diagnostic workup and treatment, standardized clinical workflows, and quality assurance. Structured reporting also facilitates scientific and computer-based further usage of radiology data [1] [11].

According to a number of large radiology societies, the improvement of report quality by using structured reporting is a high priority [11] [12]. Consequently, the Radiological Society of North America (RSNA) created the Radlex, a lexicon of standard radiology terminology that is now also available in German at https://www.drg.de/de-DE/4291/radlex-deutsch/ [13]. Moreover, the RSNA and the European Society of Radiology (ESR) created the free platform www.radreport.org, which provides standardized reporting templates for various radiological examinations in HTML-5 or IHE-MRRT format.

The German Society of Radiology and the German Society of Neuroradiology are providing support for the development of structured templates in German. In collaboration with the various working groups of the German Society of Radiology and the German Society of Neuroradiology, the Information Technology working group (@GIT) is creating, validating, and certifying specialty- and case-specific templates in consensus. The structured reporting template presented here for examinations of patients with acute ischemic stroke by non-contrast computed tomography, CT angiography, and CT perfusion is provided online at www.befundung.drg.de in a free database and comments can be added at [e-mail] or https://github.com/DRGagit/ak_befundung.

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