Brain MRI Findings Checklist
Complete this checklist to document brain MRI findings, technical quality, and recommended follow-up from the imaging review.
Patient and Exam Details
Patient age
*
Age range
Please Select
0–17
18–29
30–44
45–59
60–74
75+
Prefer not to say
Sex
Female
Male
Intersex
Prefer not to say
Referring clinician name
First Name
Middle Name
Last Name
Exam date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MRI study date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Imaging facility or department
Primary reason for MRI
*
MRI Sequence and Image Quality
Sequences Obtained
*
T1-weighted
T2-weighted
FLAIR
DWI
ADC
GRE/SWI
Post-contrast
Other
Image Quality Rating
*
1
2
3
4
5
Motion/Artifact Limits Interpretation
*
No
Mild
Moderate
Severe
Brain MRI Findings Checklist
Acute infarct / ischemia
*
Normal
Abnormal present
Not assessed
Hemorrhage
*
Normal
Abnormal present
Not assessed
Mass lesion / tumor
*
Normal
Abnormal present
Not assessed
Edema
*
Normal
Abnormal present
Not assessed
Midline shift
*
Absent
Present
Not assessed
Hydrocephalus
*
Absent
Present
Not assessed
Hydrocephalus severity
Please Select
Mild
Moderate
Severe
Not applicable
Extra-axial collection
*
Absent
Present
Not assessed
Demyelinating plaques
*
Absent
Present
Not assessed
White matter changes
*
Normal
Mild
Moderate
Severe
Not assessed
Atrophy
*
Absent
Present
Not assessed
Encephalomalacia
*
Absent
Present
Not assessed
Aneurysm / vascular abnormality
*
Absent
Present
Not assessed
Pituitary / sellar abnormality
*
Absent
Present
Not assessed
Posterior fossa abnormality
*
Absent
Present
Not assessed
Diffusion restriction
*
Absent
Present
Not assessed
Findings details: laterality, location, size, and severity
Rows
Laterality
Location
Size
Severity
Acute infarct / ischemia
1
2
3
4
Hemorrhage
5
6
7
8
Mass lesion / tumor
9
10
11
12
Edema
13
14
15
16
Extra-axial collection
17
18
19
20
Demyelinating plaques
21
22
23
24
Encephalomalacia
25
26
27
28
Aneurysm / vascular abnormality
29
30
31
32
Pituitary / sellar abnormality
33
34
35
36
Posterior fossa abnormality
37
38
39
40
Anatomical Location and Severity
Laterality
*
Left
Right
Bilateral
Midline
Brain Region
*
Please Select
Frontal
Parietal
Temporal
Occipital
Cerebellum
Brainstem
Basal Ganglia
Thalamus
Corpus Callosum
Sellar/Parasellar
Lesion Size / Measurement
Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Chronicity
*
New
Chronic
Indeterminate
Impression and Follow-Up
Overall Impression Summary
*
Urgent Finding Present?
*
Yes
No
Recommended Follow-Up Action
*
Please Select
None
Clinical correlation
Repeat imaging
Contrast MRI
Neurology referral
Neurosurgery referral
Emergency department evaluation
Radiologist / Reader Name or Initials
*
First Name
Middle Name
Last Name
Submit
Should be Empty: