Purpose or Case Report: The radiology report is a tool to communicate information to the referring physician and record data for follow-up or research purposes. With structured reporting templates information becomes uniform, comprehensive and easily manageable. In collaboration with neonatologists and information technologists we developed a structured MRI reporting template for neonatal hypoxic-ischemic encephalopathy (HIE).
Methods & Materials: A systematic reporting template (iSORT for HIE) was developed based on the literature data and the retrospective analysis of fifty term neonates with the clinical diagnosis of asphyxia. MRI studies were performed with a Philips Achieva 3T MR scanner between 2007 and 2014. The key findings on T1-, T2-, T2*/SWI, diffusion weighted MR images and single voxel MR-spectroscopy were evaluated. The proposed reporting system, iSORT for HIE is an "easy walk through" template in a web-based framework, which we initially started using in research.
Results: The iSORT outline follows a tree structure, directs focus on the most characteristic imaging findings seen in neonatal HIE. Although the full reporting template consists of about 500 questions, only the relevant headings and subheadings are to be filled as the report progresses. The first section is composed of patient data and the technical aspects of the MRI examination. The second part records signal intensity changes in nested anatomic landmarks. We created a third section with an objective and semi-objective scaling system, to evaluate neonates with a baseline MRI study and a 2-year follow-up neurologic examination.
Conclusions: Here we introduced iSORT for HIE, a novel structured reporting template for MRI examinations. Getting used to the iSORT system, the data recording is faster and the information is more detailed compared to a conventional report. The search for a particular term is easily achievable with only a mouse-click input. Besides the benefits in research, the template is useful in the everyday clinical practice by reducing interpretation ambiguity. Hence it may have a direct positive impact on patient care.