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Brain PET Studies

SYNOPTIC - STRUCTURED REPORT -  KEY ELEMENTS

• STRUCTURED TEMPLATES

The written report is the final product of the Nuclear Medicine consultation. Reports must contain specific information to identify the patient, the specific procedure, indications for the examination, radiopharmaceutical used and activity administered, route of administration, interval between tracer administration and imaging, succinct technical information about data acquisition and processing (especially the use and dose of additional drugs such as adenosine, CCK, morphine, lasix, etc), specific image and data analysis findings, and a conclusion.

The report should be concise, clear and specific. Standard anatomic designations and physiologic descriptors should be used. Jargon terms, such as "defect" or "photopenia", should not appear in the report. When possible, lesions should be specifically enumerated, physical size measured, and uptake quantified. When lesions are very numerous, the major areas of involvement should be specifically identified. When previous examinations are available, the improvement, progression or stability of disease should be identified. Examples of specific reports are contained with a description of each of the imaging procedures.

• GENERAL STRUCTURE

The following elements should be included in all reports:

Patient identifier: Name, gender, birth date, medical record number 

Date procedure started and date reported

Procedure Title

Indication: Brief statement of clinical problem and question to be answered

Technical factors: Radiopharmaceutical, dose, route of administration, type of scan, interval between injection and imaging, interventions

Reference to prior examination of the same type

Reference to other procedures

Findings: Address clinical question first.

Interpretation: As definitive as possible and avoid repetition of findings.

• BRAIN [¹⁸F]FDG PET/CT PERFORMED [date]

Clinical Statement: [age] year old [Female/Male] with focal seizures.

Comparison: [None]

Correlation: [None]

Technique: Following intravenous injection of [18F]FDG and a [60] minute waiting time, low dose CT and PET images of the brain were acquired on the [YYY] PET/CT scanner. [No] intravenous contrast was administered.

Plasma glucose at the time of injection was [XX] mg/dL

The SUV values were normalized to the patient body weight, and indicate the highest activity concentration (SUVmax) at a given site.

Findings:

     Ventricles/sulci/cisterns:  No abnormal uptake

     Cortex:  There is a focus of decreased [18F]FDG uptake in the left anterior temporal lobe.

     White matter:  No abnormal uptake

     Basal Ganglia:  No abnormal uptake

     Cerebellum:  No abnormal uptake

     Skull/soft tissue/skin:  No abnormal uptake