# RadCommons — full corpus

> Every system in RadCommons as Markdown. 121 systems. Sourced or blank, never invented. An initiative of Laudos.AI.
> Index: https://radcommons.laudos.ai/llms.txt · API: https://radcommons.laudos.ai/api/v1/systems

# ACR Incidental Adrenal — ACR incidental adrenal mass management

> Management pathway for incidentally detected adrenal masses based on imaging features and size.

**Status:** current · **Organ:** Adrenal · **Issuing body:** American College of Radiology · **Version:** 2017 · **Year:** 2017

## Provenance and currency
- Family: incidental finding
- Logic type: flat
- Modality: CT, MRI
- Primary source: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Apply the benign-feature and cancer-history precedence before size. Return the exact source branch and required safety caveats; the 2017 algorithm is guidance, not an autonomous diagnosis or treatment order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| benign-features | Benign imaging features | Adult incidental asymptomatic adrenal mass with a diagnostic benign feature: unenhanced CT attenuation <=10 HU; signal loss relative to spleen from in-phase to opposed-phase chemical-shift MRI; no enhancement (<10 HU change between precontrast and postcontrast images), consistent with cyst or hemorrhage; or benign calcification. Macroscopic fat is represented by the more specific macroscopic-fat branch. | No additional imaging workup or follow-up is needed once a diagnostic benign feature is established, regardless of size. Imaging cannot establish functional status, so the paper separately advises considering biochemical evaluation for most incidental adrenal masses when clinically relevant. | The 2017 algorithm treats these imaging findings as benign leave-alone endpoints. This classification does not exclude hormonal activity and does not publish a branch-specific numeric probability of malignancy. | Mayo-Smith et al., JACR 2017, Fig. 1 and p.4 'Masses With Diagnostic Benign Imaging Features'; p.5 defines no enhancement as <10 HU change; pp.6-7 discuss functional assessment. | ✓ |
| indeterminate | Indeterminate mass | Adrenal mass >=1 cm without a diagnostic benign feature after applying prior-imaging, cancer-history and size precedence. Examples include attenuation >10 HU on unenhanced CT and incomplete or nondiagnostic characterization. In a patient without cancer and without prior stability, the 2017 branches distinguish 1-2 cm, >2 to <4 cm, and >=4 cm masses. | First review prior imaging: stability for >=1 year ends imaging follow-up. With no cancer history, consider dedicated adrenal CT follow-up at 12 months for a 1-2 cm mass; obtain a dedicated adrenal CT at detection for a >2 to <4 cm mass. Adenoma is supported by absolute washout >=60% or relative washout >=40%. If characterization remains indeterminate, choose 6-12 month imaging, PET/CT, biopsy or resection according to the full clinical scenario rather than the attenuation value alone. | Indeterminate is not a calibrated malignancy-risk percentage. New or enlarging lesions and larger size increase concern, but the paper states that no validated growth-rate threshold separates benign from malignant adrenal masses. | Mayo-Smith et al., JACR 2017, Fig. 1; pp.4-5 'Masses Without Diagnostic Features (>=1 to <4 cm)' and adrenal CT protocol; APW/RPW formulas and >=60%/>=40% thresholds on p.5. | ✓ |
| macroscopic-fat | Macroscopic fat (myelolipoma) | Adrenal mass containing macroscopic fat, which the 2017 ACR incidental-mass algorithm identifies as diagnostic of a myelolipoma and routes to a benign endpoint. | No additional imaging workup or follow-up is needed under this incidental-mass algorithm. Consider biochemical assessment only as clinically indicated because imaging characterization and functional status are separate questions. | Macroscopic fat is a diagnostic benign feature in the 2017 flowchart and no branch-specific malignancy percentage is supplied. Apply the stated algorithm only in its incidental, asymptomatic adult scope. | Mayo-Smith et al., JACR 2017, Fig. 1 diagnostic-benign branch; p.3 reporting considerations and p.4 'Masses With Diagnostic Benign Imaging Features' identify macroscopic fat as myelolipoma. | ✓ |
| large-mass | Large mass | Isolated adrenal mass >=4 cm with no diagnostic benign imaging feature and no history of cancer. 'Isolated' means that no other metastatic disease is identified. | Consider surgical resection without biopsy for possible primary adrenocortical carcinoma. Determine functional status and exclude pheochromocytoma before biopsy or resection; the branch is not an instruction to biopsy a possible primary adrenal cortical carcinoma. | Larger size is qualitatively more suspicious and motivates the >=4 cm branch, but the white paper does not assign a numeric malignancy probability to this category. | Mayo-Smith et al., JACR 2017, Fig. 1 >=4 cm/no-cancer branch and footnotes 1 and 3; p.5 'Masses Without Diagnostic Features (>=4 cm)'. | ✓ |
| prior-malignancy | Known prior malignancy | Known malignancy plus an adrenal mass without a diagnostic benign feature or documented >=1-year stability. The pathway considers size, whether the lesion is isolated, growth, central necrosis and the result of dedicated adrenal CT characterization. | Review priors first. For an indeterminate 1 to <4 cm mass without prior stability, obtain dedicated adrenal CT without and with contrast. Consider FDG-PET/CT or image-guided biopsy when the mass is new or enlarging, centrally necrotic, remains indeterminate, or is >=4 cm; PET/CT also evaluates occult extra-adrenal disease. Exclude pheochromocytoma before biopsy. | Metastasis is more likely in a patient with known malignancy than without it, yet the paper emphasizes that even in oncology patients most incidental adrenal masses are benign. No patient-specific numeric risk is assigned to this branch. | Mayo-Smith et al., JACR 2017, Fig. 1 cancer-history branches; pp.4-5 cancer-history pathway; p.6 PET/CT and adrenal-biopsy sections. | ✓ |

### Per-category citations
- **benign-features**: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001 · Mayo-Smith et al., JACR 2017, Fig. 1 and p.4 'Masses With Diagnostic Benign Imaging Features'; p.5 defines no enhancement as <10 HU change; pp.6-7 discuss functional assessment.
- **indeterminate**: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001 · Mayo-Smith et al., JACR 2017, Fig. 1; pp.4-5 'Masses Without Diagnostic Features (>=1 to <4 cm)' and adrenal CT protocol; APW/RPW formulas and >=60%/>=40% thresholds on p.5.
- **macroscopic-fat**: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001 · Mayo-Smith et al., JACR 2017, Fig. 1 diagnostic-benign branch; p.3 reporting considerations and p.4 'Masses With Diagnostic Benign Imaging Features' identify macroscopic fat as myelolipoma.
- **large-mass**: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001 · Mayo-Smith et al., JACR 2017, Fig. 1 >=4 cm/no-cancer branch and footnotes 1 and 3; p.5 'Masses Without Diagnostic Features (>=4 cm)'.
- **prior-malignancy**: Mayo-Smith WW, Song JH, Boland GL, et al.. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.05.001 · Mayo-Smith et al., JACR 2017, Fig. 1 cancer-history branches; pp.4-5 cancer-history pathway; p.6 PET/CT and adrenal-biopsy sections.

## Cross-references
- _shared boundary_ → [ACR Incidental Pancreatic Cyst — ACR incidental pancreatic cyst management](https://radcommons.laudos.ai/systems/acr-incidental-panc-cyst-2017.md) — Both are ACR Incidental Findings Committee white papers in the same series.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2017-08-01 | published | ACR Incidental Findings Committee adrenal white paper published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/acr-incidental-adrenal-2017 · API JSON: https://radcommons.laudos.ai/api/v1/systems/acr-incidental-adrenal-2017 · Agent index: https://radcommons.laudos.ai/llms.txt

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# Bismuth-Corlette — Modified Bismuth-Corlette classification of perihilar cholangiocarcinoma

> Five-type map of longitudinal tumor extension through the primary and right/left secondary biliary confluences. It does not encode vascular invasion, lobar atrophy, nodal or distant disease, future liver remnant, resectability or prognosis and cannot prescribe a resection or drainage route by itself.

**Status:** current · **Organ:** Biliary · **Issuing body:** Bismuth and Corlette / hepatobiliary surgery · **Version:** 1975 framework; 1992 modification; 2025 EASL staging boundary · **Year:** 1975

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI, CT
- Primary source: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use modified Bismuth-Corlette only for the longitudinal duct map. Always expose confluences, vessels, atrophy, metastases and future liver remnant separately; no type automatically determines resection, drainage, transplant or prognosis.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Tumor extends within the common hepatic duct but remains below the primary right-left hepatic-duct confluence; the primary confluence and both right and left secondary ductal confluences are spared. Confirm the map on preintervention MRI/MRCP when possible and state actual ductal variants. | Treat type I as a longitudinal duct descriptor, not an instruction for bile-duct-only resection, right hepatectomy or ERCP. A specialist hepatobiliary multidisciplinary team determines R0 resection feasibility from the inferior margin, vessels, lobar atrophy, nodes, metastases, future liver remnant, fitness and anatomy. Avoid routine preoperative drainage; when a separate indication exists, route and target are individualized. | Type I has the least proximal ductal extent in this framework but no validated independent survival or resectability probability. Margin feasibility, tumor biology, nodal or distant disease, vascular involvement, future liver remnant and patient fitness dominate prognosis; do not describe type I as low-risk cancer solely from the numeral. | Bismuth and Corlette 1975, PMID 1079096, original lineage; Bismuth et al. 1992, PMC1242367, modified surgical framework; EASL CPG 2025, DOI 10.1016/j.jhep.2025.03.007, pCCA radiology, staging, resectability, surgery and biliary-drainage sections. | ✓ |
| II | Type II | Tumor involves the primary right-left hepatic-duct confluence but spares both the right and left secondary ductal confluences. Mere contact near the hilum is insufficient: report whether the primary confluence is truly infiltrated and whether both secondary confluences remain assessable and free. | Map both secondary confluences, hepatic artery and portal vein, lobar atrophy, future liver remnant and metastases before deciding resectability or resection extent. Type II does not universally select a right-sided operation or endoscopic drainage. If preoperative drainage is clinically required, target the intended future liver remnant and select endoscopic or percutaneous access from anatomy and expertise rather than type alone. | Type II implies primary-confluence involvement and greater ductal complexity than type I, but the classification has no type-II-specific calibrated prognosis. An anatomically resectable type II with favorable margins and nodes may have a different outlook from a metastatic type I; formal AJCC stage and multidisciplinary resectability variables must remain separate. | Bismuth-Corlette five-type anatomy as retained in EASL 2025 and Dar et al. 2024 PMC10989497; EASL diagnosis/staging and surgical sections for MRI/MRCP, multiphasic CT, AJCC and non-Bismuth resectability fields; drainage section for indication- and anatomy-led access. | ✓ |
| IIIa | Type IIIa | Tumor involves the primary confluence and extends into the RIGHT secondary ductal confluence, while the left secondary confluence remains spared. Map right anterior and posterior sectoral ducts and variants; vague extension into a proximal right duct is not enough when the secondary confluence cannot be assessed. | A right-sided or extended resection may be considered, but IIIa never automatically means right trisectionectomy. The operative plan depends on actual sectoral anatomy, arterial and portal involvement, ipsilateral or contralateral atrophy, achievable margins and the volume, function and drainage of the future liver remnant. Drainage is not routine and its route cannot be selected from IIIa alone. | Unilateral secondary-confluence involvement increases reconstruction and margin complexity but supplies no independent IIIa survival percentage. Resectability and outcome depend on contralateral duct preservation, vessels, lobar atrophy, future liver remnant, nodes, metastases, biology and center expertise rather than the suffix a. | Modified Bismuth-Corlette anatomy in Bismuth et al. 1992, PMC1242367, and current EASL 2025 pCCA sections; Dar et al. 2024, PMC10989497, Bismuth classification, preoperative imaging and surgical-resection factors for type III planning. | ✓ |
| IIIb | Type IIIb | Tumor involves the primary confluence and extends into the LEFT secondary ductal confluence, while the right secondary confluence remains spared. Map the left sectoral ducts and any right-sided variant draining into the left system before assigning the side-specific suffix. | A left-sided or extended resection may be considered, but IIIb never automatically means left trisectionectomy. Determine the side and extent from ductal variants, vascular involvement, lobar atrophy, margins and future liver remnant. If biliary drainage has an independent indication, drain viable intended remnant liver and choose the route through multidisciplinary expertise, not the IIIb token. | Type IIIb indicates unilateral left secondary-confluence extension but is not a prognostic stage or a calibrated operative-risk group. Individual outcome is driven by R0 feasibility, vascular and metastatic disease, nodes, future liver remnant, physiology and treatment pathway. Avoid claiming that IIIa and IIIb have an intrinsic ordinal risk difference. | Bismuth et al. 1992 modified framework; EASL 2025 MRI/MRCP anatomy, CT vascular/metastatic staging, resectability and drainage guidance; Dar et al. 2024 surgical-planning discussion including biliary extent, atrophy, vascular involvement, dominance and variants. | ✓ |
| IV | Type IV | Tumor involves BOTH right and left secondary ductal confluences; modified formulations also include multifocal or discontinuous bilateral ductal disease. Name the exact bilateral confluences or skip lesions and distinguish true tumor from stent-related inflammation or inadequate post-drainage visualization. | Type IV is not automatically unresectable. Expert multidisciplinary assessment may identify selected candidates for complex R0 resection or a protocolized transplant pathway, while metastatic, vascular, remnant-liver or physiologic factors may preclude either. Do not assign trisectionectomy, transplantation or combined endoscopic/percutaneous drainage from the label; each requires its own anatomic and clinical eligibility gate. | Type IV denotes the broadest ductal extent and often high technical complexity, but modern expert centers have resected selected type-IV tumors and the code does not yield an individual survival probability. Prognosis depends on margins, nodes, metastases, vascular involvement, remnant liver, biology, treatment eligibility and response; transplant-series survival must not be attributed to all type-IV patients. | Modified Bismuth-Corlette bilateral/multifocal definition; EASL 2025 evidence review noting resection across Bismuth types and superiority of broader staging for resectability/survival; EASL surgery, transplant and drainage sections; Dar et al. 2024, selected type-IV surgical boundary. | ✓ |

### Per-category citations
- **I**: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/ · Bismuth and Corlette 1975, PMID 1079096, original lineage; Bismuth et al. 1992, PMC1242367, modified surgical framework; EASL CPG 2025, DOI 10.1016/j.jhep.2025.03.007, pCCA radiology, staging, resectability, surgery and biliary-drainage sections.
- **II**: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/ · Bismuth-Corlette five-type anatomy as retained in EASL 2025 and Dar et al. 2024 PMC10989497; EASL diagnosis/staging and surgical sections for MRI/MRCP, multiphasic CT, AJCC and non-Bismuth resectability fields; drainage section for indication- and anatomy-led access.
- **IIIa**: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/ · Modified Bismuth-Corlette anatomy in Bismuth et al. 1992, PMC1242367, and current EASL 2025 pCCA sections; Dar et al. 2024, PMC10989497, Bismuth classification, preoperative imaging and surgical-resection factors for type III planning.
- **IIIb**: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/ · Bismuth et al. 1992 modified framework; EASL 2025 MRI/MRCP anatomy, CT vascular/metastatic staging, resectability and drainage guidance; Dar et al. 2024 surgical-planning discussion including biliary extent, atrophy, vascular involvement, dominance and variants.
- **IV**: Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver (1975) — https://pubmed.ncbi.nlm.nih.gov/1079096/ · Modified Bismuth-Corlette bilateral/multifocal definition; EASL 2025 evidence review noting resection across Bismuth types and superiority of broader staging for resectability/survival; EASL surgery, transplant and drainage sections; Dar et al. 2024, selected type-IV surgical boundary.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-05-01 | revised | The EASL extrahepatic-cholangiocarcinoma guideline retained Bismuth as a longitudinal ductal descriptor while defining modern cross-sectional staging, resectability and drainage boundaries; it did not create a new Bismuth type set. | confirmed |
| 1992-01-01 | revised | Bismuth, Nakache and Diamond published the modified surgical-strategy framework underlying the current five-type Bismuth-Corlette map. | confirmed |
| 1975-02-01 | published | Bismuth and Corlette introduced a ductal-extent framework for carcinoma of the hepatic hilum. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bismuth-corlette · API JSON: https://radcommons.laudos.ai/api/v1/systems/bismuth-corlette · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Csendes — Csendes classification of Mirizzi syndrome

> Classifies Mirizzi syndrome by extrinsic bile-duct compression versus circumferential loss from a cholecystobiliary fistula, then adds cholecystoenteric fistula and gallstone ileus as a type V overlay.

**Status:** current · **Organ:** Biliary · **Issuing body:** Csendes et al. · **Version:** 1989 + 2008 type V extension · **Year:** 1989

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI, CT, US
- Primary source: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return a base type I-IV plus a Va/Vb overlay whenever type V applies. Keep preoperative suspicion separate from definitive wall-loss classification and use the result to communicate anatomy, not to order an operation.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, extrinsic compression without fistula | External compression of the common hepatic duct or common bile duct by an impacted gallstone at the gallbladder infundibulum, neck, or cystic duct, without a cholecystobiliary fistula or bile-duct-wall loss. | Flag distorted hilar and Calot-triangle anatomy before dissection and define the duct and stone relationship. The original series reported cholecystectomy with duct exploration or drainage as effective, but the type is a planning descriptor and does not prescribe a current operation. | Even without a duct-wall fistula, inflammation and distorted anatomy create bile-duct and vascular injury risk. Type I does not provide a calibrated complication probability and should not be inferred from upstream dilatation alone. | Csendes et al. 1989, PMID 2597969, abstract: Type I external compression; original operative discussion for Type I and increasing morbidity with lesion severity. | ✓ |
| II | Type II, cholecystobiliary fistula up to one-third wall loss | Cholecystobiliary fistula produced by gallstone erosion with a limited bile-duct-wall defect involving up to approximately one-third of the duct circumference. | Report the fistula and estimated wall fraction because a limited defect may permit repair or choledochoplasty in expert hands. The original series described absorbable suture or choledochoplasty using gallbladder remnant; current technique remains individualized. | A true duct-wall defect increases the complexity and risk of bile leak, stricture and iatrogenic duct injury compared with external compression alone. The code supplies no patient-specific event percentage. | Csendes et al. 1989, PMID 2597969, abstract: Type II fistula with less than one-third wall erosion and original repair options; Beltran et al. 2008 restatement uses one-third. | ✓ |
| III | Type III, fistula up to two-thirds wall loss | Cholecystobiliary fistula with a larger bile-duct-wall defect extending beyond the Type II range and involving up to approximately two-thirds of the duct circumference. | Communicate the large wall defect for hepatobiliary reconstruction planning. The original series advised against simple fistula suture and recommended choledochoplasty; the exact contemporary operation depends on tissue quality and anatomy. | The larger wall defect implies more difficult reconstruction and greater operative morbidity than limited erosion in the original severity trend, but Type III is not a calibrated outcome score. | Csendes et al. 1989, PMID 2597969, abstract: Type III fistula up to two-thirds of duct circumference, simple suture not indicated, choledochoplasty recommended. | ✓ |
| IV | Type IV, complete bile-duct-wall destruction | Cholecystobiliary fistula with complete circumferential destruction of the bile-duct wall, with the gallbladder and duct fused into a single inflammatory structure. | Flag complete wall loss for complex hepatobiliary reconstruction. The original series preferred a bilioenteric anastomosis, but imaging or type alone must not order a procedure or define the reconstruction. | Complete wall destruction is the most extensive I-IV biliary defect and was associated with the highest end of the original increasing morbidity and mortality trend. No individual risk percentage is encoded by the class. | Csendes et al. 1989, PMID 2597969, abstract: Type IV complete duct destruction, bilioenteric anastomosis preferred, operative morbidity and mortality increasing with lesion severity. | ✓ |
| Va | Type Va, cholecystoenteric fistula without gallstone ileus | Any underlying Csendes Type I-IV Mirizzi lesion with a coexisting cholecystoenteric fistula and no gallstone ileus. The involved organ can be duodenum, stomach, colon, or another directly fistulized viscus. | Report and plan for both components: the underlying I-IV biliary defect and the enteric fistula or involved organ. The 2008 series repaired enteric fistulas in the context of varied base-type operations; Va alone does not select a single procedure. | Va adds adjacent-organ involvement, difficult inflammatory planes and risk of enteric, biliary and vascular injury. The 2008 cohort showed complications rising with biliary severity, but Va is not a patient-specific risk percentage and remains incomplete without the base I-IV type. | Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Type V any base type plus cholecystoenteric fistula; Va without gallstone ileus), Results on involved organs and procedures, Tables 5-6 and Discussion. | ✓ |
| Vb | Type Vb, cholecystoenteric fistula with gallstone ileus | Any underlying Csendes Type I-IV Mirizzi lesion with a cholecystoenteric fistula and gallstone ileus, meaning mechanical bowel obstruction caused by a gallstone that entered through the fistula. | Treat bowel obstruction as an urgent separate problem while preserving the underlying biliary type. The 2008 validation supports a staged strategy in selected patients and often used enterolithotomy first, but physiology, obstruction site, fistula anatomy and specialist judgment determine timing and procedures. | Vb adds acute mechanical bowel obstruction to the biliary and enteric-fistula hazards. It is not simply one ordinal step above Va and does not encode an individual mortality, recurrence or operative-complication probability. | Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Vb with gallstone ileus), Results describing enterolithotomy and Discussion supporting two-stage surgery in selected gallstone-ileus patients. | ✓ |

### Per-category citations
- **I**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Csendes et al. 1989, PMID 2597969, abstract: Type I external compression; original operative discussion for Type I and increasing morbidity with lesion severity.
- **II**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Csendes et al. 1989, PMID 2597969, abstract: Type II fistula with less than one-third wall erosion and original repair options; Beltran et al. 2008 restatement uses one-third.
- **III**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Csendes et al. 1989, PMID 2597969, abstract: Type III fistula up to two-thirds of duct circumference, simple suture not indicated, choledochoplasty recommended.
- **IV**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Csendes et al. 1989, PMID 2597969, abstract: Type IV complete duct destruction, bilioenteric anastomosis preferred, operative morbidity and mortality increasing with lesion severity.
- **Va**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Type V any base type plus cholecystoenteric fistula; Va without gallstone ileus), Results on involved organs and procedures, Tables 5-6 and Discussion.
- **Vb**: Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification (1989) — https://pubmed.ncbi.nlm.nih.gov/2597969/ · Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Vb with gallstone ileus), Results describing enterolithotomy and Discussion supporting two-stage surgery in selected gallstone-ileus patients.

## Cross-references
- _shared boundary_ → [Bismuth-Corlette — Modified Bismuth-Corlette classification of perihilar cholangiocarcinoma](https://radcommons.laudos.ai/systems/bismuth-corlette.md) — Both describe obstruction at the biliary confluence: Mirizzi from extrinsic stone impaction and fistula, Bismuth-Corlette from hilar cholangiocarcinoma.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2008-10-01 | revised | Beltran and Csendes validated type V as any underlying I-IV Mirizzi lesion with a cholecystoenteric fistula, divided into Va without and Vb with gallstone ileus. | confirmed |
| 2008-01-01 | revised | Csendes classification extended with type V (cholecystoenteric fistula; Va and Vb) by Beltran and Csendes. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/csendes-mirizzi · API JSON: https://radcommons.laudos.ai/api/v1/systems/csendes-mirizzi · Agent index: https://radcommons.laudos.ai/llms.txt

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# Todani — Todani classification of congenital bile duct cysts

> Classifies congenital bile duct cysts by the exact intrahepatic, extrahepatic and intraduodenal segments involved; the code must preserve classical subtypes, mapped anatomy, complications and uncertainty without selecting treatment by itself.

**Status:** current · **Organ:** Biliary · **Issuing body:** Todani et al. / hepatopancreatobiliary literature · **Version:** 1977 original; 2003 anatomic clarification · **Year:** 1977

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRCP, MRI, CT, US, ERCP
- Primary source: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Map the complete biliary tree before assigning I-V, preserve Ia/Ib/Ic and IVa/IVb when resolvable, surface complications and uncertainty, and keep the anatomic code separate from diagnosis, patient-specific cancer prediction and treatment selection.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | A solitary congenital cystic or fusiform dilatation of the extrahepatic bile duct without congenital intrahepatic duct ectasia. Preserve subtype when anatomy supports it: Ia involves essentially the entire extrahepatic duct cystically, Ib is focal/segmental, and Ic is diffuse smooth fusiform extrahepatic dilatation. | Complete biliary mapping and hepatopancreatobiliary referral are appropriate. Specialist literature generally favors extrahepatic cyst excision with cholecystectomy and bilioenteric reconstruction when feasible, but age, inflammation, prior intervention, distal duct anatomy and local expertise determine the actual plan. | Complications include cholangitis, pancreatitis, stones, stricture and malignancy. In a 2,904-patient meta-analysis, overall malignancy prevalence across all types was 10.7%, and types I/IV accounted for nearly all reported cancers; this pooled retrospective estimate is not an individual prediction and risk persists after treatment. | Soares et al. 2014, PMC4332770, Classification and Management sections/Figure 1 for Ia-Ic anatomy and type I treatment context; ten Hove et al. 2018, PMC5900735, Results and Tables 2-3 for pooled and type-stratified malignancy. | ✓ |
| II | Type II | A true diverticulum arising from the extrahepatic bile duct through a discrete neck, with the remaining duct otherwise near normal. Distinguish it from a focal type Ib cyst, cystic-duct lesion, gallbladder duplication and adjacent noncommunicating cyst by showing the neck and duct communication. | Specialist assessment commonly considers diverticulectomy; the width and location of the neck and integrity of the parent duct determine primary repair versus biliary reconstruction. The Todani label itself does not select a procedure. | Type II was uncommon in the malignancy meta-analysis and had far less observed cancer than types I/IV. The small type-specific sample and retrospective follow-up do not establish zero malignant risk; obstruction, stones, cholangitis and procedural duct injury remain relevant. | Soares et al. 2014, PMC4332770, Classification, Differential Diagnosis and Management sections for true extrahepatic diverticulum morphology, mimics and excision context; ten Hove et al. 2018, PMC5900735, type-stratified malignancy analysis and sample-size limitations. | ✓ |
| III | Type III (choledochocele) | A choledochocele: cystic dilatation of the intramural/intraduodenal distal common bile duct that protrudes toward the duodenal lumen. Distal duct prominence alone is insufficient; show the ampullary or intraduodenal relationship and distinguish duodenal duplication cyst or periampullary diverticulum. | Symptomatic or complicated lesions may be evaluated for endoscopic sphincterotomy/unroofing or selected surgical treatment according to size, epithelial lining, common-channel anatomy and local expertise. Imaging classification alone must not order intervention. | Reported malignant transformation is lower than for types I/IV, but type III cohorts are small and do not prove absence of risk. Pancreatitis, obstruction, cholangitis and stone formation can occur, and mucosal or mural abnormalities require direct evaluation. | Soares et al. 2014, PMC4332770, Classification, Clinical Differentiation and Management sections for intraduodenal anatomy, differential and endoscopic/surgical context; ten Hove et al. 2018, PMC5900735, type II/III subgroup limitations. | ✓ |
| IV | Type IV | Multiple congenital bile duct dilatations. IVa involves both intrahepatic and extrahepatic ducts; IVb consists of multiple extrahepatic dilatations only. The subtype is mandatory when resolvable, with lobar distribution, dominant intrahepatic strictures and residual drainage anatomy described separately. | IVb commonly follows an extrahepatic excision/reconstruction framework. IVa additionally requires specialist mapping of intrahepatic strictures and burden; selected patients may need hepatic resection, drainage planning or transplant evaluation. The Roman numeral is not an autonomous surgical instruction. | Type IV shares the major malignancy signal with type I and can produce recurrent cholangitis, hepatolithiasis, strictures, cirrhosis and portal hypertension. Residual intrahepatic disease and post-reconstruction anatomy require long-term specialist follow-up; pooled cancer figures must not be individualized mechanically. | Todani et al. 2003, DOI 10.1007/s00534-002-0733-7, pp. 340-344 for IVa/primary-stricture clarification; Soares et al. 2014, PMC4332770, classification and type IV management; ten Hove et al. 2018, PMC5900735, Tables 2-3 for I/IV malignancy predominance. | ✓ |
| V | Type V (Caroli disease) | Congenital communicating segmental saccular or fusiform dilatation confined to the intrahepatic bile ducts (Caroli disease), without an extrahepatic cyst. Caroli syndrome adds congenital hepatic fibrosis and portal-hypertension features, which must be stated because the Todani V code alone does not encode fibrosis. | Localized unilobar disease may be assessed for hepatic resection; diffuse bilateral disease with recurrent cholangitis, portal-hypertension complications or liver failure may prompt transplant evaluation. Infection, stones and obstruction need direct management independent of the code. | Recurrent cholangitis, intrahepatic stones, abscess, fibrosis/cirrhosis and cholangiocarcinoma are important long-term risks. A central-dot sign supports but does not independently prove Caroli disease, and mimics such as PSC, recurrent pyogenic cholangitis and peribiliary cysts must be excluded. | Soares et al. 2014, PMC4332770, Type V/Caroli classification, differential and management sections for intrahepatic-only communication, localized versus diffuse management and complications; ten Hove et al. 2018, PMC5900735, malignancy background and type-distribution discussion. | ✓ |

### Per-category citations
- **I**: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/ · Soares et al. 2014, PMC4332770, Classification and Management sections/Figure 1 for Ia-Ic anatomy and type I treatment context; ten Hove et al. 2018, PMC5900735, Results and Tables 2-3 for pooled and type-stratified malignancy.
- **II**: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/ · Soares et al. 2014, PMC4332770, Classification, Differential Diagnosis and Management sections for true extrahepatic diverticulum morphology, mimics and excision context; ten Hove et al. 2018, PMC5900735, type-stratified malignancy analysis and sample-size limitations.
- **III**: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/ · Soares et al. 2014, PMC4332770, Classification, Clinical Differentiation and Management sections for intraduodenal anatomy, differential and endoscopic/surgical context; ten Hove et al. 2018, PMC5900735, type II/III subgroup limitations.
- **IV**: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/ · Todani et al. 2003, DOI 10.1007/s00534-002-0733-7, pp. 340-344 for IVa/primary-stricture clarification; Soares et al. 2014, PMC4332770, classification and type IV management; ten Hove et al. 2018, PMC5900735, Tables 2-3 for I/IV malignancy predominance.
- **V**: Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst (1977) — https://pubmed.ncbi.nlm.nih.gov/889044/ · Soares et al. 2014, PMC4332770, Type V/Caroli classification, differential and management sections for intrahepatic-only communication, localized versus diffuse management and complications; ten Hove et al. 2018, PMC5900735, malignancy background and type-distribution discussion.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-01 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2003-10-01 | revised | Todani and colleagues clarified type Ic and type IVa anatomy, including primary ductal strictures, without replacing the classical I-V framework. | confirmed |
| 1977-08-01 | published | Todani and colleagues published the expanded congenital bile duct cyst classification and operative anatomy in the American Journal of Surgery. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/todani · API JSON: https://radcommons.laudos.ai/api/v1/systems/todani · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# VI-RADS — Vesical Imaging Reporting and Data System

> Multiparametric MRI risk stratification of bladder cancer muscle invasion.

**Status:** current · **Organ:** Bladder · **Issuing body:** VI-RADS working group · **Version:** 2018 · **Year:** 2018

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | VI-RADS 1, muscle invasion highly unlikely | Muscle invasion highly unlikely. All sequences are category 1: on T2WI an uninterrupted low-signal line indicates an intact muscularis propria; on DWI the muscle layer shows continuous intermediate signal (lesion under 1 cm); on DCE there is no early enhancement of the muscularis propria. | Below the validated VI-RADS >=3 muscle-invasion cutoff: low-probability lesion managed as non-muscle-invasive disease (e.g. transurethral resection / TURBT) rather than treated as muscle-invasive; multiparametric MRI reduces the need for upfront re-resection. | Muscle invasion highly unlikely; in validation studies, scores of 1-2 correspond to a low probability of muscle-invasive bladder cancer, well below the >=3 threshold (pooled sensitivity ~0.87-0.92 / specificity ~0.82-0.86 for the >=3 cutoff). | PMC6690492 (Panebianco et al., Eur Urol 2018), Sect. 3.2.5 'Final scoring' with 3.2.4.2/3.2.4.3/3.2.4.4; Table 2 (criteria, 'muscle invasion highly unlikely'). Cutoff/performance from validation meta-analysis summarized in PMC10493860 (VI-RADS >=3 optimal cutoff). | ✓ |
| 2 | VI-RADS 2, muscle invasion unlikely | Muscle invasion unlikely. The low-signal muscularis line remains uninterrupted; typically an exophytic tumor with a stalk and/or a thickened high-signal inner layer on T2WI, with corresponding category-2 DWI/DCE (continuous intermediate-signal muscle on DWI for lesions over 1 cm; early enhancement of the inner layer but not the muscle on DCE). | Below the >=3 cutoff: treated as non-muscle-invasive disease. For a small T1 tumor with a clear stalk and no muscularis-propria involvement the goal is a complete (radical) TURBT, generally without mandatory re-resection. | Muscle invasion unlikely; scores 1-2 carry a low probability of muscle-invasive cancer and fall below the >=3 muscle-invasion threshold in validation studies. | PMC6690492, Sect. 3.2.5 with 3.2.4.2/3.2.4.3/3.2.4.4; Table 2; TURBT-goal statement from Sect. 3.3.2 ('radical TURBT should be the goal' for stalked T1). Cutoff context from PMC10493860. | ✓ |
| 3 | VI-RADS 3, equivocal | Equivocal for muscle invasion. Category-2 features are absent but there is no clear interruption of the low-signal muscularis propria (e.g. exophytic tumor lacking a stalk, or a sessile/broad-based tumor without a clearly thickened inner layer). When T2WI is equivocal, DWI (first) then DCE drive the assessment. | Equivocal zone at the validated >=3 cutoff: warrants careful surgical planning — a deeper-invading T1 tumor (T1b/c) makes a mandatory re-TUR appropriate, and clinicians should weigh treating as potentially muscle-invasive. | Equivocal probability of muscle invasion. VI-RADS 3 is the validated 'watershed' cutoff: using score >=3 to predict muscle invasion gives pooled sensitivity ~0.87-0.92 and specificity ~0.82-0.86 (about 90% accuracy in prospective cohorts). | PMC6690492, Sect. 3.2.5 ('equivocal') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; re-TUR statement from Sect. 3.3.2 ('re-TUR should be mandatory' for T1b/c). >=3 cutoff performance from validation meta-analysis in PMC10493860. | ✓ |
| 4 | VI-RADS 4, muscle invasion likely | Muscle invasion likely. At least one sequence is category 4: on T2WI the low-signal muscularis line is interrupted, suggesting tumor extension into the muscularis propria; DWI shows high-signal tumor (low ADC) extending focally into the muscle; DCE shows early-enhancing tumor extending focally into the muscularis propria. | At/above the muscle-invasion cutoff: high suspicion of muscle-invasive bladder cancer; supports treating as muscle-invasive disease and proceeding toward definitive staging/management (e.g. radical cystectomy pathway) rather than relying on TURBT alone. | Muscle invasion likely; in validation studies a score >=4 is highly specific for muscle invasion (pooled specificity ~0.94-0.96, sensitivity ~0.78), i.e. high positive predictive value when present. | PMC6690492, Sect. 3.2.5 ('muscle invasion likely') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; >=4 cutoff specificity/sensitivity from validation meta-analysis in PMC10493860. | ✓ |
| 5 | VI-RADS 5, invasion of or beyond muscle very likely | Invasion of muscle and beyond the bladder very likely. Intermediate-signal tumor extends into the extravesical fat on T2WI; on DWI/DCE the high-signal or early-enhancing tumor extends through the entire bladder wall into the perivesical fat. | Very high suspicion of muscle-invasive (and extravesical) disease: managed along the muscle-invasive/advanced pathway with definitive staging and treatment (e.g. radical cystectomy +/- neoadjuvant chemotherapy as clinically indicated), not TURBT alone. | Invasion of muscle and beyond the bladder very likely; highest VI-RADS probability of muscle-invasive disease, well above the >=3 cutoff and within the high-specificity >=4 range. | PMC6690492, Sect. 3.2.5 ('invasion of muscle and beyond the bladder very likely') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; cutoff context from PMC10493860. | ✓ |

### Per-category citations
- **1**: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/ · PMC6690492 (Panebianco et al., Eur Urol 2018), Sect. 3.2.5 'Final scoring' with 3.2.4.2/3.2.4.3/3.2.4.4; Table 2 (criteria, 'muscle invasion highly unlikely'). Cutoff/performance from validation meta-analysis summarized in PMC10493860 (VI-RADS >=3 optimal cutoff).
- **2**: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/ · PMC6690492, Sect. 3.2.5 with 3.2.4.2/3.2.4.3/3.2.4.4; Table 2; TURBT-goal statement from Sect. 3.3.2 ('radical TURBT should be the goal' for stalked T1). Cutoff context from PMC10493860.
- **3**: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/ · PMC6690492, Sect. 3.2.5 ('equivocal') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; re-TUR statement from Sect. 3.3.2 ('re-TUR should be mandatory' for T1b/c). >=3 cutoff performance from validation meta-analysis in PMC10493860.
- **4**: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/ · PMC6690492, Sect. 3.2.5 ('muscle invasion likely') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; >=4 cutoff specificity/sensitivity from validation meta-analysis in PMC10493860.
- **5**: Panebianco V, Narumi Y, Altun E, et al.. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System) (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6690492/ · PMC6690492, Sect. 3.2.5 ('invasion of muscle and beyond the bladder very likely') with 3.2.4.2/3.2.4.3/3.2.4.4 and Table 2; cutoff context from PMC10493860.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2018-05-01 | published | VI-RADS published in European Urology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/vi-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/vi-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# ASPECTS — Alberta Stroke Program Early CT Score

> A 10 point topographic score of early ischemic change in the middle cerebral artery territory on non-contrast CT.

**Status:** current · **Organ:** Brain · **Issuing body:** Alberta Stroke Program · **Version:** 2000 · **Year:** 2000

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT
- Primary source: Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke (ASPECTS) (2000) — https://doi.org/10.1016/S0140-6736(00)02237-6
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Calculate and report the exact 0-10 score plus involved regions and modality. The legacy RadCommons outcome bands are interpretive outputs; current EVT selection requires the additional variables encoded in EVT_2026_context.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 10 | Normal scan, no early ischemic change | Exact ASPECTS 10: no early ischemic change in any of the ten assessed regions of the affected middle cerebral artery territory on noncontrast CT. Start at 10 and subtract one point for each involved region: C, L, IC, I, and M1-M6. | ASPECTS 10 alone neither mandates nor excludes reperfusion. For ICA or M1 large-vessel occlusion with NIHSS at least 6 and prestroke mRS 0-1, the 2026 AHA/ASA guideline recommends EVT within 6 hours and from 6-24 hours when the other eligibility criteria are met. | This is the least extensive end of the ASPECTS early-ischemic-change scale. Higher baseline scores were associated with better functional outcome and lower symptomatic hemorrhage risk in the original thrombolysis cohort, but the score is not an individual prognosis. | Barber et al., Lancet 2000, Methods pp 1671-1672 and Fig 1; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1-2. | ✓ |
| >=6 | Scores 6-9, limited regional early ischemic change | Legacy RadCommons interpretation band for exact scores 6-9 because exact score 10 is represented separately. Each lost point denotes early ischemic change in one of the ten MCA regions; report the exact numeric score and involved regions rather than the band alone. | ASPECTS at least 6 is only one EVT input. For ICA or M1 occlusion with NIHSS at least 6 and prestroke mRS 0-1, EVT is recommended within 6 hours and from 6-24 hours under the 2026 AHA/ASA guideline; vessel, time, function, examination, and other imaging criteria must also be checked. | Scores 6-9 indicate less extensive regional early ischemic change than scores 0-5. Higher ASPECTS is generally associated with more favorable outcomes, but no score supplies a standalone probability or treatment result. | Barber et al., Lancet 2000, Methods pp 1671-1672 and Results/Discussion pp 1672-1673; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1-2. | ✓ |
| <6 | Scores 0-5, larger early ischemic change burden | Exact ASPECTS 0-5, indicating early ischemic change in at least five of the ten assessed MCA regions. This combined legacy band must be split into scores 3-5 versus 0-2 before applying current endovascular-treatment guidance. | Do not use ASPECTS below 6 as an automatic thrombectomy exclusion. In otherwise eligible ICA/M1 occlusion, EVT is recommended for ASPECTS 3-5 within 6 hours; from 6-24 hours it is recommended in selected patients younger than 80 with NIHSS at least 6, prestroke mRS 0-1, and no significant mass effect. For selected ASPECTS 0-2 patients younger than 80 with the same core clinical criteria and no significant mass effect, EVT within 6 hours is reasonable. | Lower ASPECTS reflects more extensive early ischemic change and was associated with worse functional outcome and greater symptomatic hemorrhage risk in the original cohort. It is not synonymous with wholly irreversible tissue and is not a standalone futility rule. | Barber et al., Lancet 2000, Methods pp 1671-1672 and Discussion p 1673; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1, 3, and 4. | ✓ |

### Per-category citations
- **10**: Prabhakaran S, Gonzalez NR, Zachrison KS, et al.. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (2026) — https://doi.org/10.1161/STR.0000000000000513 · Barber et al., Lancet 2000, Methods pp 1671-1672 and Fig 1; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1-2.
- **>=6**: Prabhakaran S, Gonzalez NR, Zachrison KS, et al.. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (2026) — https://doi.org/10.1161/STR.0000000000000513 · Barber et al., Lancet 2000, Methods pp 1671-1672 and Results/Discussion pp 1672-1673; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1-2.
- **<6**: Prabhakaran S, Gonzalez NR, Zachrison KS, et al.. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (2026) — https://doi.org/10.1161/STR.0000000000000513 · Barber et al., Lancet 2000, Methods pp 1671-1672 and Discussion p 1673; AHA/ASA 2026 AIS Guideline section 4.7.2, recommendations 1, 3, and 4.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2000-05-13 | published | ASPECTS validated in the Lancet. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aspects · API JSON: https://radcommons.laudos.ai/api/v1/systems/aspects · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Fazekas — Fazekas visual rating of periventricular and deep white matter hyperintensities

> Two separate 0-3 MRI ratings for periventricular and deep white matter hyperintensity burden. Preserve both raw scores and lesion pattern: Fazekas is a burden descriptor, not an etiologic diagnosis, dementia biomarker, individual-risk calculator or grade-only treatment rule.

**Status:** current · **Organ:** Brain · **Issuing body:** Fazekas et al. / STRIVE · **Version:** 1987 original two-axis scale; STRIVE-2 terminology and 2023 incidental-WMH care context · **Year:** 1987

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Fazekas F, Chawluk JB, Alavi A, et al.. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging (1987) — https://doi.org/10.2214/ajr.149.2.351
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Return the two original location-specific ratings. A single number is acceptable only when its external protocol and aggregation rule are named and both raw axes remain available.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Score 0, absent on the rated axis | Rate each original axis separately. Periventricular WMH score 0 means no periventricular hyperintensity; deep WMH score 0 means no deep white-matter hyperintense focus. Do not substitute one undifferentiated global score for the two raw ratings. | No treatment or follow-up action follows from a score of 0. If neurologic symptoms or another imaging abnormality is present, evaluate that problem on its own merits; absence of WMH does not close the clinical differential. | This is the no-burden reference state for the rated axis, not proof of neurologic health and not a calibrated probability of future stroke, cognitive decline, gait impairment or dementia. | Fazekas et al., AJR 1987;149:351-356, PMID 3496763, original separate periventricular and deep WMH ratings; Ottavi et al., Med J Aust 2023;219:278-284, DOI 10.5694/mja2.52079, Box 3 and consensus recommendations for the grade-independent incidental-WMH care boundary. | ✓ |
| 1 | Score 1, caps or thin lining / punctate deep foci | Rate each axis separately. Periventricular score 1 is caps or a pencil-thin lining around the ventricles; deep score 1 is punctate foci. Record both raw scores even when a local protocol also reports their maximum as a summary. | For an incidental typical WMH pattern, review neurologic-event history and cardiovascular risks such as blood pressure, diabetes, lipids and smoking, then manage identified risks under usual guidance. Do not start aspirin, anticoagulation or a statin solely for this grade. | A small punctate burden can be common with increasing age and is nonspecific. The original small cohort found punctate or early confluent deep lesions in both Alzheimer and control participants, so grade 1 does not establish vascular or neurodegenerative etiology. | Fazekas et al., AJR 1987, PMID 3496763, abstract and original morphology definitions; Wardlaw et al., STRIVE, PMC3714437, WMH terminology; Ottavi et al. 2023, DOI 10.5694/mja2.52079, consensus recommendations on cardiovascular screening and against antiplatelet or anticoagulant use solely for incidental WMH. | ✓ |
| 2 | Score 2, smooth halo / beginning deep confluence | Rate each axis separately. Periventricular score 2 is a smooth halo; deep score 2 is beginning or early confluence of previously punctate foci. A smooth halo is not the irregular deep extension of periventricular score 3. | Correlate moderate burden with age, symptoms, lesion distribution, comparison studies and vascular risks. Address identified risks using standard clinical guidance and assess an atypical pattern or unexplained symptoms separately; the score alone does not determine medication, referral or MRI interval. | More extensive WMH burden is associated at population level with adverse neurologic and functional outcomes, but no current source supplies a transportable individual probability for score 2. Etiology and prognosis still depend on pattern and clinical context. | Fazekas et al., AJR 1987, PMID 3496763, separate periventricular halo and deep beginning-confluence definitions; Duering et al., STRIVE-2 2023, DOI 10.1016/S1474-4422(23)00131-X, current small-vessel-disease imaging context; Ottavi et al. 2023, DOI 10.5694/mja2.52079, grade-independent care recommendations. | ✓ |
| 3 | Score 3, irregular periventricular extension / large deep confluence | Rate each axis separately. Periventricular score 3 is irregular hyperintensity extending into adjacent deep white matter; deep score 3 is large confluent areas. State which axis is 3 rather than reporting severe Fazekas disease without location. | Integrate confluent burden with age, symptoms, gait or cognitive concerns, longitudinal change and other small-vessel-disease markers. Optimize confirmed cardiovascular risks and seek neurologic assessment for rapidly progressive, unexplained or radiologically atypical findings; never prescribe from grade 3 alone. | Confluent WMH represents the greatest burden on the rated axis and is associated with worse outcomes at population level. It is not a diagnosis of dementia, not proof of vascular cause and not an individualized forecast of stroke, cognitive decline or mortality. | Fazekas et al., AJR 1987, PMID 3496763, original irregular periventricular extension and confluent deep-WMH definitions; Wardlaw et al., STRIVE, PMC3714437, and Duering et al., STRIVE-2, DOI 10.1016/S1474-4422(23)00131-X, terminology and interpretation; Ottavi et al. 2023, DOI 10.5694/mja2.52079, incidental-WMH management and referral context. | ✓ |

### Per-category citations
- **0**: Fazekas F, Chawluk JB, Alavi A, et al.. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging (1987) — https://doi.org/10.2214/ajr.149.2.351 · Fazekas et al., AJR 1987;149:351-356, PMID 3496763, original separate periventricular and deep WMH ratings; Ottavi et al., Med J Aust 2023;219:278-284, DOI 10.5694/mja2.52079, Box 3 and consensus recommendations for the grade-independent incidental-WMH care boundary.
- **1**: Fazekas F, Chawluk JB, Alavi A, et al.. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging (1987) — https://doi.org/10.2214/ajr.149.2.351 · Fazekas et al., AJR 1987, PMID 3496763, abstract and original morphology definitions; Wardlaw et al., STRIVE, PMC3714437, WMH terminology; Ottavi et al. 2023, DOI 10.5694/mja2.52079, consensus recommendations on cardiovascular screening and against antiplatelet or anticoagulant use solely for incidental WMH.
- **2**: Fazekas F, Chawluk JB, Alavi A, et al.. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging (1987) — https://doi.org/10.2214/ajr.149.2.351 · Fazekas et al., AJR 1987, PMID 3496763, separate periventricular halo and deep beginning-confluence definitions; Duering et al., STRIVE-2 2023, DOI 10.1016/S1474-4422(23)00131-X, current small-vessel-disease imaging context; Ottavi et al. 2023, DOI 10.5694/mja2.52079, grade-independent care recommendations.
- **3**: Fazekas F, Chawluk JB, Alavi A, et al.. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging (1987) — https://doi.org/10.2214/ajr.149.2.351 · Fazekas et al., AJR 1987, PMID 3496763, original irregular periventricular extension and confluent deep-WMH definitions; Wardlaw et al., STRIVE, PMC3714437, and Duering et al., STRIVE-2, DOI 10.1016/S1474-4422(23)00131-X, terminology and interpretation; Ottavi et al. 2023, DOI 10.5694/mja2.52079, incidental-WMH management and referral context.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2023-09-18 | revised | STRIVE-2 updated small-vessel-disease imaging terminology and the Medical Journal of Australia consensus supplied incidental-WMH care context. Neither source replaced the original Fazekas category map or converted it into a treatment scale. | confirmed |
| 1987-08-01 | published | Fazekas scale described in AJR. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/fazekas · API JSON: https://radcommons.laudos.ai/api/v1/systems/fazekas · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Fisher — Original Fisher CT grouping for aneurysmal subarachnoid hemorrhage

> Historical four-group CT blood-distribution system developed to study later cerebral vasospasm after aneurysmal SAH. Group 3, not group 4, carried the strongest original association; thick SAH remains group 3 even when ICH or IVH is present. It is not an ordinal injury-severity scale, a current-vasospasm test or a treatment algorithm.

**Status:** current · **Organ:** Brain · **Issuing body:** Fisher et al. / neurovascular literature · **Version:** 1980 original grouping; interpretation corrected 2019; aSAH care context through 2026 · **Year:** 1980

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning (1980) — https://doi.org/10.1227/00006123-198001000-00001
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the term original Fisher group, follow the explicit classification priority, and never map a bare number to modified Fisher or to a treatment decision.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | Original Fisher group 1: no subarachnoid blood is detected on the CT and there is no intracerebral or intraventricular clot that would meet group 4. Record scan timing and quality because blood can be unapparent or clear over time. | A negative CT category is not a rule-out pathway. If aneurysmal SAH is suspected or confirmed, continue the time-appropriate emergency diagnostic and neurovascular pathway; do not discharge, withhold aneurysm evaluation or omit surveillance because the group is 1. | No visible blood was the low-blood historical reference, but group 1 is not a current individual vasospasm or DCI probability and does not mean that suspected SAH, delayed imaging or limited CT technique is benign. | Fisher et al., Neurosurgery 1980;6:1-9, DOI 10.1227/00006123-198001000-00001, original group definitions; Rosen and Macdonald, PMC3621041, Table 6; Vergouwen et al., joint ESO/EANS/ESMINT guideline 2026, PMC13151661, current emergency aSAH care independent of group. | ✓ |
| 2 | Grade 2 | Original Fisher group 2: diffuse subarachnoid blood or thin vertical layers, with every vertical layer less than 1 mm and no localized clot. Intracerebral or intraventricular clot with only this thin pattern instead meets group 4. | Treat suspected or confirmed aneurysmal SAH as an emergency and use current specialist care, aneurysm-securing, nimodipine and DCI-monitoring guidance as clinically appropriate. Original group 2 alone neither mandates nor withholds a procedure or medication. | Thin diffuse blood had a weaker historical vasospasm association than the localized or thick group-3 pattern. The original ordering is nonmonotonic and does not provide a modern patient-specific probability of vasospasm, DCI or outcome. | Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001; Rosen and Macdonald, PMC3621041, Table 6, diffuse or vertical layers less than 1 mm; Komiyama 2019, PMC6838856, group-2/group-4 boundary; Vergouwen et al. 2026, PMC13151661, current aSAH care. | ✓ |
| 3 | Grade 3 | Original Fisher group 3: a localized subarachnoid clot and/or any vertical subarachnoid blood layer at least 1 mm thick. This remains group 3 when intracerebral or intraventricular clot coexists; exactly 1 mm is on the group-3 side. | Use current aneurysmal-SAH emergency care and close neurologic/DCI surveillance based on the complete clinical picture. The historically strongest vasospasm association does not itself diagnose current vasospasm or select clipping, coiling, hemodynamic augmentation or another intervention. | This pattern had the strongest original and early prospective association with later severe cerebral vasospasm. That historical signal is qualitative here and must not be converted into a contemporary individual percentage or a diagnosis of present DCI. | Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001, localized clot and thick vertical-layer group; Kistler et al., Neurology 1983, PMID 6682190, prospective historical association; Komiyama 2019, PMC6838856, thick SAH plus IVH or ICH remains original group 3; Vergouwen et al. 2026, PMC13151661, current care. | ✓ |
| 4 | Grade 4 | Original Fisher group 4: intracerebral or intraventricular clot with only diffuse thin subarachnoid blood or no subarachnoid blood. If localized clot or a vertical SAH layer at least 1 mm is present, classify as original group 3 instead. | Follow the emergency aneurysmal-SAH pathway and separately assess IVH or ICH, hydrocephalus, ventricular obstruction, mass effect and deterioration. Group 4 does not itself choose CSF diversion, surgery, endovascular therapy or the intensity of treatment. | Original group 4 had a lower historical vasospasm association than group 3, demonstrating the scale's nonmonotonic design. This does not imply less hemorrhagic injury, lower hydrocephalus risk, better prognosis or lower clinical acuity. | Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001; Rosen and Macdonald, PMC3621041, Table 6; Komiyama 2019, DOI 10.1177/1591019919856511 and PMC6838856, full clarification that group 4 requires diffuse or no SAH with ICH or IVH; Vergouwen et al. 2026, PMC13151661, current care context. | ✓ |

### Per-category citations
- **1**: Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning (1980) — https://doi.org/10.1227/00006123-198001000-00001 · Fisher et al., Neurosurgery 1980;6:1-9, DOI 10.1227/00006123-198001000-00001, original group definitions; Rosen and Macdonald, PMC3621041, Table 6; Vergouwen et al., joint ESO/EANS/ESMINT guideline 2026, PMC13151661, current emergency aSAH care independent of group.
- **2**: Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning (1980) — https://doi.org/10.1227/00006123-198001000-00001 · Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001; Rosen and Macdonald, PMC3621041, Table 6, diffuse or vertical layers less than 1 mm; Komiyama 2019, PMC6838856, group-2/group-4 boundary; Vergouwen et al. 2026, PMC13151661, current aSAH care.
- **3**: Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning (1980) — https://doi.org/10.1227/00006123-198001000-00001 · Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001, localized clot and thick vertical-layer group; Kistler et al., Neurology 1983, PMID 6682190, prospective historical association; Komiyama 2019, PMC6838856, thick SAH plus IVH or ICH remains original group 3; Vergouwen et al. 2026, PMC13151661, current care.
- **4**: Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning (1980) — https://doi.org/10.1227/00006123-198001000-00001 · Fisher et al. 1980, DOI 10.1227/00006123-198001000-00001; Rosen and Macdonald, PMC3621041, Table 6; Komiyama 2019, DOI 10.1177/1591019919856511 and PMC6838856, full clarification that group 4 requires diffuse or no SAH with ICH or IVH; Vergouwen et al. 2026, PMC13151661, current care context.

## Cross-references
- _shared boundary_ → [Modified Fisher — Modified Fisher CT scale for aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/modified-fisher.md) — The original Fisher groups and modified Fisher grades use different category maps. Original group 4 means ICH or IVH with diffuse thin or no SAH; modified Fisher grade 4 means thick SAH with IVH.
- _supersedes_ → [Modified Fisher — Modified Fisher CT scale for aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/modified-fisher.md) — The modified Fisher scale refines the original Fisher grading of subarachnoid blood.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-26 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2019-06-10 | revised | Komiyama published an interpretive clarification of the common group-4 misreading: thick or localized SAH remains group 3 even with ICH or IVH; group 4 requires diffuse thin or no SAH with ICH or IVH. This did not revise the original category definitions. | confirmed |
| 1980-01-01 | published | Fisher, Kistler and Davis published four CT blood-distribution groups for aneurysmal SAH and their historical relation to later cerebral vasospasm. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/fisher · API JSON: https://radcommons.laudos.ai/api/v1/systems/fisher · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# GCA — Original Pasquier cerebral atrophy regional scale

> Original MRI protocol rates 13 total regional sulcal and ventricular sites from 0 to 3 and sums them to 0-39. A later simplified global 0-3 impression is an adaptation, not the original total. Preserve protocol, regional pattern, asymmetry and modality; GCA does not diagnose Alzheimer disease or prescribe treatment.

**Status:** current · **Organ:** Brain · **Issuing body:** Pasquier et al. / neuroradiology practice · **Version:** 1996 original 13-region sum; simplified global 0-3 adaptation must be labeled · **Year:** 1996

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI, CT
- Primary source: Pasquier F, Leys D, Weerts JG, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts (1996) — https://pubmed.ncbi.nlm.nih.gov/8864706/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Preserve the protocol identity. The original Pasquier result is thirteen component scores summed to 0-39; a single global 0-3 impression is a labeled later adaptation.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Regional score 0, no atrophy | Regional score 0 means normal gyral volume without sulcal opening for a cortical region, or no enlargement for a ventricular region. In the original protocol this code is assigned independently to each of 13 total regions before summation to 0-39. | No action follows from regional score 0 or a simplified global score 0. Normal-appearing global volume does not exclude early or focal disease; investigate persistent cognitive or neurologic symptoms using the appropriate clinical pathway. | This is the no-visible-atrophy morphology for the rated region, not a probability of normal cognition and not an exclusion of biomarker-defined or focal neurodegenerative disease. | Pasquier et al., Eur Neurol 1996;36:268-272, PMID 8864706 and DOI 10.1159/000117270, original 13-region architecture; Vernooij and van Buchem, Neuroimaging in Dementia, NCBI Bookshelf NBK554327, Fig 11.3 and Table 11.1, score-0 morphology and diagnostic limits. | ✓ |
| 1 | Regional score 1, mild sulcal or ventricular enlargement | Regional score 1 means opening of cortical sulci without definite gyral volume loss, or mild enlargement of the rated ventricular region. The same morphology words may be used in a simplified overall 0-3 adaptation, which must be labeled separately. | Interpret mild atrophy with age, symptoms, side, lobar pattern and comparison imaging. Do not order medication, biomarkers, follow-up or referral from score 1 alone; pursue clinical assessment when symptoms or an atypical focal or asymmetric pattern warrant it. | Mild generalized volume loss can accompany aging and is nonspecific. Score 1 supplies no validated individual probability of dementia, Alzheimer pathology, conversion or functional decline. | Pasquier et al. 1996, PMID 8864706, regional visual assessment framework; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, opening-of-sulci and mild-ventricular-enlargement descriptors plus age and pattern context; Jack et al. 2024, DOI 10.1002/alz.13859, Alzheimer biomarker boundary. | ✓ |
| 2 | Regional score 2, moderate gyral loss or ventricular enlargement | Regional score 2 means visible gyral volume loss with further sulcal widening, or moderate enlargement of the rated ventricular region. Preserve side and region; in original mode sum all 13 component ratings rather than reporting 2 as a global total. | When moderate atrophy is unexpected for age or matches cognitive or neurologic symptoms, integrate clinical assessment and the regional pattern with disease-specific testing as appropriate. The grade itself does not diagnose dementia or dictate a biomarker, drug or interval. | Moderate atrophy may be clinically concerning, particularly in a younger patient or a focal or asymmetric pattern, but score 2 has no universal age cutoff and no calibrated individual dementia or progression probability. | Pasquier et al. 1996, DOI 10.1159/000117270, original regional scale and reproducibility; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, reduced gyral volume, wider sulci, moderate ventricular enlargement and rule-of-thumb age context; Hobden et al. 2024, PMC10942897, CT-versus-MRI reliability context. | ✓ |
| 3 | Regional score 3, severe knife-blade atrophy or ventricular enlargement | Regional score 3 means severe knife-blade gyral volume loss with markedly widened sulci, or severe enlargement of the rated ventricular region. State the affected region and side and distinguish generalized atrophy from focal destructive change or hydrocephalus. | Severe, focal, asymmetric or clinically concordant atrophy warrants integrated neurologic or cognitive evaluation and etiologic work-up as appropriate to the presentation. Score 3 alone does not establish Alzheimer disease, choose treatment or define treatment eligibility. | This is the greatest visual atrophy burden on the rated region and is treated as abnormal at any age in later dementia-imaging teaching, but it still supplies no individual probability of a specific disease, conversion, disability or survival. | Pasquier et al. 1996, PMID 8864706, original regional rating; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, knife-blade and severe-enlargement descriptors and age-context caution; Jack et al. 2024, DOI 10.1002/alz.13859, biologic Alzheimer criteria; Hobden et al. 2024, PMC10942897, modality reliability context. | ✓ |

### Per-category citations
- **0**: Pasquier F, Leys D, Weerts JG, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts (1996) — https://pubmed.ncbi.nlm.nih.gov/8864706/ · Pasquier et al., Eur Neurol 1996;36:268-272, PMID 8864706 and DOI 10.1159/000117270, original 13-region architecture; Vernooij and van Buchem, Neuroimaging in Dementia, NCBI Bookshelf NBK554327, Fig 11.3 and Table 11.1, score-0 morphology and diagnostic limits.
- **1**: Pasquier F, Leys D, Weerts JG, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts (1996) — https://pubmed.ncbi.nlm.nih.gov/8864706/ · Pasquier et al. 1996, PMID 8864706, regional visual assessment framework; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, opening-of-sulci and mild-ventricular-enlargement descriptors plus age and pattern context; Jack et al. 2024, DOI 10.1002/alz.13859, Alzheimer biomarker boundary.
- **2**: Pasquier F, Leys D, Weerts JG, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts (1996) — https://pubmed.ncbi.nlm.nih.gov/8864706/ · Pasquier et al. 1996, DOI 10.1159/000117270, original regional scale and reproducibility; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, reduced gyral volume, wider sulci, moderate ventricular enlargement and rule-of-thumb age context; Hobden et al. 2024, PMC10942897, CT-versus-MRI reliability context.
- **3**: Pasquier F, Leys D, Weerts JG, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts (1996) — https://pubmed.ncbi.nlm.nih.gov/8864706/ · Pasquier et al. 1996, PMID 8864706, original regional rating; Vernooij and van Buchem, NBK554327, Fig 11.3 and Table 11.1, knife-blade and severe-enlargement descriptors and age-context caution; Jack et al. 2024, DOI 10.1002/alz.13859, biologic Alzheimer criteria; Hobden et al. 2024, PMC10942897, modality reliability context.

## Cross-references
- _shared boundary_ → [Fazekas — Fazekas visual rating of periventricular and deep white matter hyperintensities](https://radcommons.laudos.ai/systems/fazekas.md) — Part of the standardized dementia MRI read: GCA for atrophy burden, Fazekas for white matter hyperintensity burden.
- _shared boundary_ → [Scheltens MTA — Scheltens medial temporal atrophy visual rating scale](https://radcommons.laudos.ai/systems/scheltens-mta.md) — GCA grades generalized cortical atrophy while Scheltens MTA grades the medial temporal lobe; both feed the dementia imaging work-up.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-26 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2024-04-01 | revised | Hobden and colleagues evaluated reliability when a simplified global cortical atrophy visual rating was applied across CT and MRI. This supports explicit modality labeling and does not replace the original 13-region sum. | confirmed |
| 1996-01-01 | published | Pasquier and colleagues published a reproducibility study of thirteen total regional 0-3 cerebral-atrophy ratings on axial T2 MRI, summed to 0-39. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/gca-pasquier · API JSON: https://radcommons.laudos.ai/api/v1/systems/gca-pasquier · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Hunt-Hess — Hunt and Hess clinical grading of aneurysmal subarachnoid hemorrhage

> Time-stamped bedside clinical grade for the presenting condition after aneurysmal subarachnoid hemorrhage. It is not derived from CT blood burden, is vulnerable to examination confounding and supplies communication/prognostic context rather than a grade-only treatment algorithm.

**Status:** current · **Organ:** Brain · **Issuing body:** Hunt and Hess / neurosurgical practice · **Version:** 1968 five-grade scale; 2023 AHA/ASA care context · **Year:** 1968

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Clinical
- Primary source: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Grade a real, time-stamped clinical examination only. Keep CT blood burden separate, expose confounders and uncertainty, and never translate a poor Hunt-Hess grade into autonomous treatment limitation or futility.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | At a documented clinical assessment time after aneurysmal subarachnoid hemorrhage, the patient is asymptomatic or has only mild headache and at most slight nuchal rigidity, remains alert, and has no focal neurologic deficit. This is a bedside clinical grade and cannot be inferred from a small CT blood burden. | Treat confirmed aneurysmal SAH as a neurovascular emergency even at grade 1 and follow current aneurysm-securing, rebleeding-prevention and neurocritical pathways. The grade communicates clinical state but does not choose clipping versus coiling, blood-pressure targets, nimodipine, monitoring intensity or disposition by itself. | Grade 1 is the least impaired canonical clinical category, but it does not mean benign disease. In one 1,200-patient single-center spontaneous-SAH cohort from 1996-2009, in-hospital mortality was 3 percent for grades 1 and 2 combined; that historical combined figure is not an individual estimate or a grade-1-specific current rate. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade I clinical definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, current aSAH care context; Lantigua et al. 2015, PMC4556224, Abstract and Table 2 for combined grade 1-2 cohort mortality. | ✓ |
| 2 | Grade 2 | The patient is alert with moderate-to-severe headache and nuchal rigidity and has no neurologic deficit other than a possible cranial-nerve palsy. Drowsiness/confusion moves the state toward grade 3; a non-cranial focal deficit conflicts with canonical grade 2 and should be exposed rather than hidden. | Grade 2 still requires the full emergency aneurysmal-SAH pathway and definitive aneurysm assessment/management. Use the time-stamped examination with aneurysm, hydrocephalus, rebleeding, CT blood burden and systemic data; do not convert grade 2 into a treatment shortcut. | Population prognosis is generally more favorable than in poor-grade SAH, but grade 2 is not low risk in isolation. The cited 1,200-patient cohort reported 3 percent in-hospital mortality for grades 1-2 combined, not separately, and cannot provide a contemporary personal forecast. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade II definition including possible cranial-nerve palsy; Hoh et al. 2023 AHA/ASA guideline; Lantigua et al. 2015, PMC4556224, cohort methods/results. | ✓ |
| 3 | Grade 3 | The time-stamped examination shows drowsiness or confusion and/or a mild focal neurologic deficit. Document consciousness, orientation, motor findings, Glasgow Coma Scale and any sedation, seizure, hydrocephalus, hypoxia or other confounder instead of recording only the numeral. | Urgently evaluate and treat the aneurysmal SAH and reversible contributors to deterioration, including hydrocephalus, rebleeding, seizure and physiologic disturbance, under current neurovascular/neurocritical guidance. Hunt-Hess 3 alone does not specify an aneurysm procedure or forecast response. | Grade 3 indicates an impaired clinical state and is associated with worse population outcomes than grades 1-2. The historical single-center cohort reported 9 percent in-hospital mortality for grade 3, but age, GCS, CT burden, aneurysm factors, complications and care decisions materially affect outcome, so the number must not be individualized. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade III definition; Lantigua et al. 2015, PMC4556224, Abstract, Methods and multivariable mortality findings; Hoh et al. 2023 AHA/ASA guideline for current management. | ✓ |
| 4 | Grade 4 | The patient is stuporous with moderate-to-severe hemiparesis and may have early decerebrate rigidity and vegetative disturbance. Distinguish stupor from deep coma and record whether sedation, intubation, paralysis or another reversible factor prevents a valid examination. | Grade 4 is poor-grade SAH requiring immediate specialist neurovascular and neurocritical evaluation, investigation of reversible causes and patient-specific aneurysm treatment planning. It is not a futility category and must not independently trigger non-intervention or withdrawal of life support. | Severe neurologic impairment carries substantial population risk. A 1996-2009 single-center spontaneous-SAH cohort reported 24 percent in-hospital mortality for grade 4, but this is a cohort-specific historical association affected by subsequent complications and treatment-limitation decisions, not an individual probability. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade IV definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, patient-centric current care; Lantigua et al. 2015, PMC4556224, mortality and mode-of-death analyses. | ✓ |
| 5 | Grade 5 | The patient is in deep coma with decerebrate rigidity and appears moribund or has failing vital centers on the contemporaneous examination. Assign only from a reliable clinical state; if sedatives, neuromuscular blockade, intubation or postictal suppression obscure the examination, return confounded rather than assuming grade 5. | Grade 5 demands immediate expert evaluation, resuscitation and assessment of reversible factors and aneurysm-treatment options under current guidance. The category alone cannot establish irreversibility, deny intervention, determine goals of care or justify withdrawal of life-sustaining treatment. | Grade 5 is the most impaired canonical clinical state and has the worst population prognosis, yet survivors exist and the grade is not deterministic. The cited historical cohort reported 71 percent in-hospital mortality, with many deaths involving brain death or withdrawal decisions; use this only as cohort context, never a personal probability or futility threshold. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade V definition; Hoh et al. 2023 AHA/ASA guideline for current care; Lantigua et al. 2015, PMC4556224, grade-specific mortality and mode-of-death results. | ✓ |

### Per-category citations
- **1**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade I clinical definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, current aSAH care context; Lantigua et al. 2015, PMC4556224, Abstract and Table 2 for combined grade 1-2 cohort mortality.
- **2**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade II definition including possible cranial-nerve palsy; Hoh et al. 2023 AHA/ASA guideline; Lantigua et al. 2015, PMC4556224, cohort methods/results.
- **3**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade III definition; Lantigua et al. 2015, PMC4556224, Abstract, Methods and multivariable mortality findings; Hoh et al. 2023 AHA/ASA guideline for current management.
- **4**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade IV definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, patient-centric current care; Lantigua et al. 2015, PMC4556224, mortality and mode-of-death analyses.
- **5**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade V definition; Hoh et al. 2023 AHA/ASA guideline for current care; Lantigua et al. 2015, PMC4556224, grade-specific mortality and mode-of-death results.

## Cross-references
- _shared boundary_ → [Modified Fisher — Modified Fisher CT scale for aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/modified-fisher.md) — Both grade aneurysmal subarachnoid hemorrhage: Hunt and Hess by clinical state, modified Fisher by CT blood burden.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1968-01-01 | published | Hunt and Hess published the five-grade clinical condition scale for patients with ruptured intracranial aneurysms. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/hunt-hess · API JSON: https://radcommons.laudos.ai/api/v1/systems/hunt-hess · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Koedam PA — Koedam posterior atrophy visual rating scale

> Bilateral 0-3 visual MRI rating of posterior cingulate and parieto-occipital sulci plus precuneus and parietal-lobe atrophy. Score each side in sagittal, axial and coronal planes and retain the worst plane per side; any bilateral aggregate must be named. Age and asymmetry remain visible, and the scale is neither an Alzheimer biomarker nor a grade-only treatment rule.

**Status:** current · **Organ:** Brain · **Issuing body:** Koedam et al. / dementia imaging literature · **Version:** 2011 original bilateral three-plane MRI scale; 2019 age norms; 2024 Alzheimer biological boundary · **Year:** 2011

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Koedam ELGE, Lehmann M, van der Flier WM, et al.. Visual assessment of posterior atrophy: development of a MRI rating scale (2011) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3217148/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Return two side-specific grades plus the decisive planes. Never collapse them silently, interpret them without age, or convert a posterior atrophy pattern into Alzheimer diagnosis, individual prognosis or treatment.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0 | Per hemisphere, grade 0 requires closed posterior cingulate and parieto-occipital sulci and closed parietal-lobe and precuneus sulci without posterior atrophy. Inspect sagittal T1, axial FLAIR and coronal T1 and retain the highest valid plane score for that side. | No Koedam grade defines treatment. A grade-0 posterior pattern does not exclude Alzheimer disease or another cause of cognitive symptoms; continue or tailor evaluation from the clinical phenotype, other imaging axes and biomarkers when clinically indicated rather than stopping work-up from this score alone. | Grade 0 is the lowest posterior-atrophy morphology, but it is not a negative Alzheimer biomarker and does not predict an individual's future cognition. The original study assessed group discrimination, not per-grade personal risk. | Koedam et al. 2011, DOI 10.1007/s00330-011-2205-4, PMC3217148, Methods: grade 0 landmarks, bilateral assessment, three planes and highest-plane rule; Jack et al. 2024, DOI 10.1002/alz.13859, biological Alzheimer boundary. | ✓ |
| 1 | Grade 1 | Per hemisphere, grade 1 is mild widening of the posterior cingulate and parieto-occipital sulci with mild parietal and precuneus atrophy, but without evident gyral volume loss. The final side score is the worst supported sagittal, axial or coronal score. | Treat grade 1 as an age-aware descriptive finding. It is common in cognitively intact adults and does not independently trigger biomarkers, medication, surveillance or a dementia label; correlate with age, symptoms, asymmetry, medial-temporal and global atrophy, white-matter disease and focal lesions. | Grade 1 occurred in 38% of the 936 cognitively intact participants in the 2019 normative study, and the higher-hemisphere 90th percentile was no more than 1 through age 59. Therefore a grade of 1 is not by itself evidence of neurodegenerative disease or a calibrated risk estimate. | Koedam et al. 2011, PMC3217148, Methods: grade 1 mild widening without evident gyral loss; Cotta Ramusino et al. 2019, DOI 10.1016/j.nicl.2019.101936, PMC6690662, PA frequency and age-stratified 90th percentiles. | ✓ |
| 2 | Grade 2 | Per hemisphere, grade 2 requires substantial widening of the posterior cingulate and parieto-occipital sulci together with visible loss of parietal-lobe and precuneus gyral volume. It is more than mild opening but does not yet require end-stage knife-blade atrophy. | Grade 2 may strengthen a posterior-predominant atrophy impression when it fits the cognitive phenotype, but it still does not select a test or therapy. Consider specialist cognitive evaluation and appropriately chosen biomarker assessment only from the whole clinical context; investigate focal or asymmetric mimics separately. | Higher posterior-atrophy scores were associated with Alzheimer-group membership and lower MMSE in the selected derivation sample, but grade 2 still fell within the higher-hemisphere 90th percentile for cognitively intact adults aged 60-84 in the normative cohort. It is nonspecific and not a personal probability of Alzheimer disease or decline. | Koedam et al. 2011, PMC3217148, Methods and Results: grade 2, group means and independent MMSE association; Cotta Ramusino et al. 2019, PMC6690662, age 60-84 PA 90th-percentile context; Jack et al. 2024, biological diagnostic boundary. | ✓ |
| 3 | Grade 3 | Per hemisphere, grade 3 is end-stage posterior atrophy with evident severe widening of the posterior cingulate and parieto-occipital sulci and knife-blade atrophy of the parietal lobes and precuneus. Preserve laterality, decisive plane and any focal structural confounder. | A grade-3 posterior pattern warrants clear communication and clinical correlation, but it does not itself diagnose Alzheimer disease or prescribe counseling, driving restrictions, medication, disease-modifying therapy or follow-up. Management requires the clinical syndrome, confirmed biology when relevant, contraindications and specialist judgment. | Grade 3 is the most severe morphology and is unusual relative to the reported cognitively intact age distributions, but it remains etiologically nonspecific. Do not convert it into certainty of Alzheimer pathology, dementia severity, future decline or a treatment ceiling. | Koedam et al. 2011, DOI 10.1007/s00330-011-2205-4, PMC3217148, Methods: grade 3 end-stage knife-blade definition; Cotta Ramusino et al. 2019, PMC6690662, normative distributions; Jack et al. 2024, DOI 10.1002/alz.13859, biomarker-based Alzheimer criteria. | ✓ |

### Per-category citations
- **0**: Koedam ELGE, Lehmann M, van der Flier WM, et al.. Visual assessment of posterior atrophy: development of a MRI rating scale (2011) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3217148/ · Koedam et al. 2011, DOI 10.1007/s00330-011-2205-4, PMC3217148, Methods: grade 0 landmarks, bilateral assessment, three planes and highest-plane rule; Jack et al. 2024, DOI 10.1002/alz.13859, biological Alzheimer boundary.
- **1**: Koedam ELGE, Lehmann M, van der Flier WM, et al.. Visual assessment of posterior atrophy: development of a MRI rating scale (2011) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3217148/ · Koedam et al. 2011, PMC3217148, Methods: grade 1 mild widening without evident gyral loss; Cotta Ramusino et al. 2019, DOI 10.1016/j.nicl.2019.101936, PMC6690662, PA frequency and age-stratified 90th percentiles.
- **2**: Koedam ELGE, Lehmann M, van der Flier WM, et al.. Visual assessment of posterior atrophy: development of a MRI rating scale (2011) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3217148/ · Koedam et al. 2011, PMC3217148, Methods and Results: grade 2, group means and independent MMSE association; Cotta Ramusino et al. 2019, PMC6690662, age 60-84 PA 90th-percentile context; Jack et al. 2024, biological diagnostic boundary.
- **3**: Koedam ELGE, Lehmann M, van der Flier WM, et al.. Visual assessment of posterior atrophy: development of a MRI rating scale (2011) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3217148/ · Koedam et al. 2011, DOI 10.1007/s00330-011-2205-4, PMC3217148, Methods: grade 3 end-stage knife-blade definition; Cotta Ramusino et al. 2019, PMC6690662, normative distributions; Jack et al. 2024, DOI 10.1002/alz.13859, biomarker-based Alzheimer criteria.

## Cross-references
- _shared boundary_ → [GCA — Original Pasquier cerebral atrophy regional scale](https://radcommons.laudos.ai/systems/gca-pasquier.md) — Koedam focuses on the posterior cortex; GCA gives the global atrophy impression.
- _shared boundary_ → [Scheltens MTA — Scheltens medial temporal atrophy visual rating scale](https://radcommons.laudos.ai/systems/scheltens-mta.md) — Complementary dementia visual rating scales: Koedam grades posterior/parietal atrophy, Scheltens grades medial temporal atrophy.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2019-08-01 | revised | A 936-participant cognitively intact reference study supplied age-stratified posterior-atrophy distributions. This is normative context, not a revision of the four category definitions. | confirmed |
| 2011-07-01 | published | Posterior atrophy visual rating scale published in European Radiology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/koedam-pca · API JSON: https://radcommons.laudos.ai/api/v1/systems/koedam-pca · Agent index: https://radcommons.laudos.ai/llms.txt

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# Marshall CT — Original Marshall CT classification of traumatic brain injury

> Time-stamped six-category traumatic-brain-injury descriptor using visible CT pathology, basal cisterns, midline shift, a greater-than-25-cm3 high- or mixed-density lesion boundary and whether a lesion was surgically evacuated. Categories are nonordinal; V is treatment-defined, and Marshall alone neither captures the complete injury nor predicts an individual outcome or chooses surgery.

**Status:** current · **Organ:** Brain · **Issuing body:** Traumatic Coma Data Bank · **Version:** 1991 original six-category system; 2024 neuroprognostication and 2025 NINDS imaging boundaries · **Year:** 1991

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the exact continuous measurements and a named timepoint. Category V is treatment-defined, the six labels are nonordinal, and the API must return the full lesion phenotype and uncertainty rather than treating Marshall as prognosis or management.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Diffuse injury I | Marshall diffuse injury I: no intracranial traumatic pathology is visible on the time-stamped CT. This means CT-negative within the classification, not absence of clinical traumatic brain injury. | Do not discharge, stop observation or withhold further assessment from class I alone. Management follows mechanism, symptoms, serial neurologic examination, anticoagulant status and validated imaging/observation rules; CT can miss small or nonhemorrhagic traumatic axonal or microvascular injuries. | Class I has the lowest visible CT injury burden in the Marshall framework, but a normal CT does not establish benign clinical course or exclude persistent symptoms and MRI-visible injury. The current neuroprognostication guideline does not support Marshall as a reliable standalone long-term mortality forecast. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category I; Mac Donald et al. 2025, DOI 10.1089/neu.2025.0079, PMC12409119, CT and MRI sensitivity limits; Muehlschlegel et al. 2024, PMC10959796, standalone prognostication boundary. | ✓ |
| II | Diffuse injury II | Marshall diffuse injury II: traumatic pathology is visible, basal cisterns remain present, midline shift is 0-5 mm inclusive, and no high- or mixed-density intracranial lesion is greater than 25 cm3. Bone fragments and foreign bodies may be present within this branch. | Class II is not an observation or nonoperative instruction. Report every lesion and integrate neurologic trajectory, lesion type, size, antithrombotic use, ICP and serial imaging; urgent trauma or neurosurgical assessment can be required despite the numeral. | Class II historically carries less mass-effect morphology than III or IV, but Marshall labels are not a calibrated ordinal risk scale and the category omits several prognostically relevant lesion types. Do not attach a single cohort mortality percentage to an individual patient. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category II; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, construction and comparative prognostic limitations; Muehlschlegel et al. 2024, PMC10959796. | ✓ |
| III | Diffuse injury III (swelling) | Marshall diffuse injury III (swelling): basal cisterns are compressed or absent, midline shift remains 0-5 mm inclusive, and no high- or mixed-density lesion is greater than 25 cm3. Exactly 5 mm remains in this branch when the other criteria are met. | Cisternal compression or absence is an urgent mass-effect feature, but class III does not specify an intervention. Escalate according to examination, pupils, ICP, lesion phenotype, systemic insults and neurosurgical/neurocritical assessment; never generate decompression or monitoring from the Roman numeral alone. | Cisternal compression is associated with more severe injury, yet class III is a population-level morphology category rather than an individual probability. Current guidance requires multivariable clinical context and explicit uncertainty for long-term counseling. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category III; Mac Donald et al. 2025, PMC12409119, cistern compression within granular imaging characterization; Muehlschlegel et al. 2024, PMC10959796, prognostication recommendations. | ✓ |
| IV | Diffuse injury IV (shift) | Marshall diffuse injury IV (shift): midline shift is greater than 5 mm and no high- or mixed-density lesion is greater than 25 cm3. If a greater-than-25-cm3 high/mixed lesion remains un-evacuated, classify VI instead; exactly 5 mm is not IV. | Greater-than-5-mm shift is an emergency imaging feature requiring immediate clinical and neurosurgical integration, but Marshall IV is not itself an operation order. Lesion-specific criteria, neurologic deterioration, pupils, ICP and serial change govern management. | Class IV can have worse outcomes than the treatment-defined class V, demonstrating that Marshall is nonordinal. It must not be used alone for long-term mortality prediction, withdrawal-of-support decisions or a ceiling of recovery. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category IV and >5-mm boundary; Thelin et al. 2017, PMC5542385, nonordinal behavior and modern performance; Muehlschlegel et al. 2024, PMC10959796, prognosis boundary. | ✓ |
| V | Evacuated mass lesion | Marshall mass lesion V: any intracranial traumatic lesion has been surgically evacuated by the stated classification timepoint. This is a treatment-defined state and can only be assigned with known operative status; preoperative volume does not define V. | Class V records that evacuation occurred; it neither recommends surgery prospectively nor proves adequacy, success or completion of care. Continue lesion-specific postoperative, ICP, examination and serial-imaging management according to the clinical course. | Because class V depends on treatment selection, it is not a pure imaging-severity category and is confounded by who underwent surgery. Do not rank it mechanically above IV or below VI, or use it as an individual outcome forecast. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, evacuated mass-lesion category; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, subsequent surgical-status and nonordinal limitations; current Brain Trauma Foundation surgical guideline for separate lesion-specific care. | ✓ |
| VI | Non-evacuated mass lesion | Marshall mass lesion VI: a high- or mixed-density intracranial lesion is greater than 25 cm3 and has not been surgically evacuated at the stated timepoint. Exactly 25 cm3 is not greater than 25 and does not enter VI solely by volume. | Class VI documents current non-evacuated status; it does not mean surgery is contraindicated, futile or permanently withheld. Urgent decisions use lesion type, location, continuous volume, shift, cisterns, GCS, pupils, deterioration, ICP, comorbidity and lesion-specific surgical guidance. | A large non-evacuated lesion indicates substantial injury burden, but VI remains a treatment- and threshold-defined category, not a deterministic mortality or functional-outcome prediction. Counsel only from a multivariable, time-aware assessment with substantial uncertainty. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, non-evacuated >25-cm3 category; Muehlschlegel et al. 2024, DOI 10.1007/s12028-023-01902-2, PMC10959796, prognostication boundary; Brain Trauma Foundation surgical guideline, distinct EDH, SDH and parenchymal-lesion thresholds. | ✓ |

### Per-category citations
- **I**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category I; Mac Donald et al. 2025, DOI 10.1089/neu.2025.0079, PMC12409119, CT and MRI sensitivity limits; Muehlschlegel et al. 2024, PMC10959796, standalone prognostication boundary.
- **II**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category II; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, construction and comparative prognostic limitations; Muehlschlegel et al. 2024, PMC10959796.
- **III**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category III; Mac Donald et al. 2025, PMC12409119, cistern compression within granular imaging characterization; Muehlschlegel et al. 2024, PMC10959796, prognostication recommendations.
- **IV**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category IV and >5-mm boundary; Thelin et al. 2017, PMC5542385, nonordinal behavior and modern performance; Muehlschlegel et al. 2024, PMC10959796, prognosis boundary.
- **V**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, evacuated mass-lesion category; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, subsequent surgical-status and nonordinal limitations; current Brain Trauma Foundation surgical guideline for separate lesion-specific care.
- **VI**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, non-evacuated >25-cm3 category; Muehlschlegel et al. 2024, DOI 10.1007/s12028-023-01902-2, PMC10959796, prognostication boundary; Brain Trauma Foundation surgical guideline, distinct EDH, SDH and parenchymal-lesion thresholds.

## Cross-references
- _shared boundary_ → [Rotterdam CT — Rotterdam CT score for traumatic brain injury](https://radcommons.laudos.ai/systems/rotterdam-ct.md) — Both summarize acute traumatic-brain-injury CT findings, but Marshall is a nonordinal six-category system with a treatment-defined evacuated-lesion class; Rotterdam is an additive prognostic score that separately encodes cisterns, shift, epidural lesion and traumatic SAH/IVH. Never convert by matching numerals.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-26 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-07-09 | revised | The NINDS TBI Imaging Working Group recommended granular lesion characterization integrated with clinical, biomarker and modifier context. Marshall remains a legacy companion classification rather than the complete injury phenotype. | confirmed |
| 2024-01-01 | revised | The Neurocritical Care Society neuroprognostication guideline concluded that Marshall should not be treated as a reliable standalone long-term mortality predictor. This is a use boundary, not a revision of the six categories. | confirmed |
| 1991-01-01 | published | Marshall and the Traumatic Coma Data Bank group published the six-category CT classification using visible pathology, cisterns, shift, lesion volume and evacuation status. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/marshall-ct · API JSON: https://radcommons.laudos.ai/api/v1/systems/marshall-ct · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# McDonald 2017 — McDonald criteria for multiple sclerosis (2017 revisions)

> Historical 2017 diagnostic algorithm for typical clinically isolated syndrome and progression from onset, integrating clinical attacks, dissemination in space, dissemination in time, and CSF-specific oligoclonal bands. A newer 2024 revision is published and must not be silently mixed into this map.

**Status:** current · **Organ:** Brain · **Issuing body:** International Panel on Diagnosis of Multiple Sclerosis · **Version:** 2017 historical version; 2024 revision published in 2025 · **Year:** 2017

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: algorithm
- Logic type: flat
- Modality: Clinical, MRI, CSF
- Primary source: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply only to an eligible clinical presentation, name the evidence for each logical gate, and keep the 2017 and 2024 rules separate. A matching MRI phrase is never enough to diagnose MS.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| periventricular | Periventricular lesion (2017 DIS region) | One of four 2017 MRI regions for dissemination in space. At least one T2-hyperintense lesion characteristic of MS in the periventricular region contributes one region; DIS requires at least one qualifying lesion in at least two of the four regions. | Report number, morphology and distribution rather than the word periventricular alone. In older patients or those with vascular risk factors, seek stronger corroboration and a higher periventricular lesion burden before attributing nonspecific lesions to MS. | A periventricular lesion is not specific for MS and supplies no individual conversion, disability or treatment-benefit probability. It cannot establish DIS or MS by itself. | Thompson et al. 2017 accepted manuscript, Panel 5 (periventricular as one of four regions and two-region DIS rule), Panel 5 footnote on older patients or vascular risk, and Panel 3 misdiagnosis safeguards. | ✓ |
| cortical-juxtacortical | Cortical or juxtacortical lesion (2017 DIS region) | One combined 2017 DIS region: a qualifying cortical or juxtacortical T2 lesion can contribute this region. Multiple cortical and juxtacortical lesions still represent one of the four regional compartments for the two-region DIS rule. | Describe whether the lesion is cortical, juxtacortical, or both and confirm that it is a true lesion rather than artifact. Use it only inside the complete clinical and regional DIS assessment. | This location supports typical distribution but is not independently diagnostic or prognostic. Standard MRI has limited sensitivity for cortical lesions and can confuse artifacts with true lesions. | Thompson et al. accepted manuscript, Panel 4 and cortical-lesion discussion (cortical added alongside juxtacortical; artifact caution), Panel 5 regional list. | ✓ |
| infratentorial | Infratentorial lesion (2017 DIS region) | One of four 2017 DIS regions, encompassing a qualifying MS-characteristic T2 lesion in the brainstem or cerebellar infratentorial compartment. Symptomatic and asymptomatic lesions can count in the 2017 framework. | Correlate the lesion with clinical findings and characterize morphology and alternative causes. Count the compartment once toward DIS and do not infer a clinical attack solely from an MRI lesion. | An infratentorial lesion does not by itself diagnose MS or quantify future relapse, disability or treatment response. Infectious, vascular, inflammatory and structural mimics remain relevant. | Thompson et al. accepted manuscript, Panels 4-5 (infratentorial region and inclusion of symptomatic lesions) and Panel 3 (integration and alternative diagnoses). | ✓ |
| spinal-cord | Spinal cord lesion (2017 DIS region) | One of four 2017 DIS regions. A qualifying T2-hyperintense spinal-cord lesion can contribute the spinal region to attack-onset DIS; the separate 2017 progression-from-onset pathway requires at least two spinal-cord T2 lesions for its spinal component. | Report level, length, morphology and acquisition adequacy, and distinguish the one-lesion attack-onset DIS rule from the two-lesion PPMS component. Do not infer neurologic deficits or a clinical attack from MRI alone. | A cord lesion is clinically important but not specific or a calibrated prognostic measure. Compressive, vascular, metabolic, infectious, NMOSD, MOGAD and other inflammatory causes require clinical exclusion as applicable. | Thompson et al. accepted manuscript, Panel 1 spinal-cord lesion definition, Panel 5 attack-onset DIS, and Panel 6 PPMS requirement of at least two cord lesions for that component. | ✓ |
| DIS | Dissemination in space demonstrated | For MRI DIS in a 2017-eligible attack-onset presentation, demonstrate at least one MS-characteristic T2 lesion in at least two of four regions: periventricular, cortical or juxtacortical, infratentorial, and spinal cord. A clinical attack at a different CNS site can also establish DIS in the applicable pathway. | Name every qualifying region and the evidence source, and continue to the correct attack-onset or progression-from-onset pathway. DIS alone is not a treatment indication and does not remove the requirement for DIT or an allowed substitute where that pathway requires it. | DIS is a binary diagnostic criterion, not a lesion-burden severity score or patient-specific prognosis. Its positive predictive value falls when applied outside the typical CIS population in which the criteria were validated. | Thompson et al. accepted manuscript, Panel 5 and Table 1 (MRI and clinical DIS routes), Panels 2-3 (validation population and misdiagnosis safeguards). | ✓ |
| DIT | Dissemination in time demonstrated | 2017 DIT can be established by a second clinical attack, simultaneous gadolinium-enhancing and nonenhancing lesions at any time, or a new T2-hyperintense or gadolinium-enhancing lesion on follow-up compared with baseline regardless of baseline timing. Symptomatic and asymptomatic lesions can count. | State the exact DIT route and comparison date. If neither a valid clinical nor MRI route exists, evaluate whether the narrowly eligible CSF-OCB substitution applies; otherwise keep DIT unmet. | DIT establishes temporal dissemination but does not quantify relapse rate, disability trajectory or treatment benefit. Enhancing and nonenhancing lesions can have mimics and do not establish MS without the remaining gates. | Thompson et al. accepted manuscript, Panel 5 (two MRI DIT alternatives and symptomatic-lesion rule), Table 1 (clinical attack and OCB routes). | ✓ |
| CSF-OCB | CSF-specific oligoclonal bands (eligible 2017 DIT substitute) | At least two oligoclonal IgG bands restricted to CSF, demonstrated with paired serum and CSF using an appropriate standardized method. In a typical CIS with DIS, no better explanation and no atypical CSF findings, this can substitute for demonstration of DIT in the 2017 attack-onset pathway. | Verify that bands are CSF-specific and review the complete CSF profile before using the substitution. OCB positivity does not replace differential diagnosis, and it is not itself literal evidence of lesions arising at different times. | CSF-specific OCBs support intrathecal antibody synthesis but are not specific for MS and are not a numeric prognosis. Markedly atypical protein, cell count or cell types argue for alternate disease assessment. | Thompson et al. accepted manuscript, CSF discussion and Panel 4 (at least two CSF-specific bands, paired testing, atypical CSF warning), Table 1 footnote stating OCBs substitute for but do not demonstrate DIT. | ✓ |
| attack-onset-MS | 2017 attack-onset MS criteria fulfilled | The appropriate 2017 attack-onset row is fully satisfied: the number of clinical attacks and objective lesion sites supplies or is supplemented by the required DIS and DIT evidence, and no better explanation remains. One attack and one objective lesion requires both DIS and DIT; one attack and at least two objective lesions requires DIT; two attacks with one objective lesion requires DIS. | Have a clinician with MS expertise integrate history, examination, MRI, CSF and differential diagnosis, document the exact pathway, and separately assign disease course and activity. The criterion result does not choose disease-modifying therapy. | Meeting the 2017 diagnostic framework does not predict an individual's relapse rate, disability, treatment response or prognosis. Misapplication outside typical presentations can reduce specificity. | Thompson et al. accepted manuscript, Table 1 complete attack-onset matrix and final no-better-explanation rule; Panel 3 clinician-integration and misdiagnosis safeguards. | ✓ |
| possible-MS | Possible MS under the 2017 framework | Use the 2017 term possible MS when a typical clinically isolated syndrome raises suspicion for MS but the complete McDonald 2017 requirements are not met and no better diagnosis has yet been established. | Identify the missing gate and use appropriate clinical follow-up, comparison MRI, spinal imaging, CSF assessment or specialist review rather than converting uncertainty into definite MS or starting a treatment solely from the label. | Possible MS is an uncertainty state, not a quantified probability of conversion and not a severity grade. The actual likelihood depends on evidence and population factors outside this label. | Thompson et al. accepted manuscript, Table 1 conclusion: incomplete criteria in suspected typical CIS are termed possible MS; Panel 3 recommends follow-up and caution for non-classical presentations. | ✓ |
| not-MS | Not MS because another diagnosis better explains the presentation | Use the 2017 not-MS state when another diagnosis arising during evaluation better explains the clinical presentation. Merely failing to meet McDonald criteria is not sufficient to declare not MS. | Name and pursue the better explanation and avoid anchoring on the MS framework. If evidence is simply insufficient and no better diagnosis is established, use the appropriate uncertainty state rather than not-MS. | This is a diagnostic disposition, not a risk stratum. It does not quantify the chance that later evidence will change the diagnosis. | Thompson et al. accepted manuscript, Table 1 final paragraph distinguishing MS, possible MS and not MS according to completion and better explanation. | ✓ |
| PPMS | 2017 primary progressive MS criteria fulfilled | 2017 progression-from-onset pathway: at least one year of disability progression independent of relapse plus at least two of three components: one or more characteristic brain T2 lesions in a periventricular, cortical or juxtacortical, or infratentorial region; at least two spinal-cord T2 lesions; or CSF-specific oligoclonal bands, with no better explanation. | Document progression duration and each of the two qualifying components, obtain strong clinical and differential-diagnosis review, and do not infer the progression history from imaging. The diagnostic code does not choose therapy. | PPMS is a disease-course diagnostic pathway, not a numeric severity or future-disability calculator. Other causes of progressive myelopathy or neurologic decline must be excluded. | Thompson et al. accepted manuscript, Panel 6 (one year progression plus two of three brain, spinal and CSF components) and Panel 3 recommendation for extra caution and CSF evaluation in progressive presentations. | ✓ |

### Per-category citations
- **periventricular**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. 2017 accepted manuscript, Panel 5 (periventricular as one of four regions and two-region DIS rule), Panel 5 footnote on older patients or vascular risk, and Panel 3 misdiagnosis safeguards.
- **cortical-juxtacortical**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panel 4 and cortical-lesion discussion (cortical added alongside juxtacortical; artifact caution), Panel 5 regional list.
- **infratentorial**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panels 4-5 (infratentorial region and inclusion of symptomatic lesions) and Panel 3 (integration and alternative diagnoses).
- **spinal-cord**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panel 1 spinal-cord lesion definition, Panel 5 attack-onset DIS, and Panel 6 PPMS requirement of at least two cord lesions for that component.
- **DIS**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panel 5 and Table 1 (MRI and clinical DIS routes), Panels 2-3 (validation population and misdiagnosis safeguards).
- **DIT**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panel 5 (two MRI DIT alternatives and symptomatic-lesion rule), Table 1 (clinical attack and OCB routes).
- **CSF-OCB**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, CSF discussion and Panel 4 (at least two CSF-specific bands, paired testing, atypical CSF warning), Table 1 footnote stating OCBs substitute for but do not demonstrate DIT.
- **attack-onset-MS**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Table 1 complete attack-onset matrix and final no-better-explanation rule; Panel 3 clinician-integration and misdiagnosis safeguards.
- **possible-MS**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Table 1 conclusion: incomplete criteria in suspected typical CIS are termed possible MS; Panel 3 recommends follow-up and caution for non-classical presentations.
- **not-MS**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Table 1 final paragraph distinguishing MS, possible MS and not MS according to completion and better explanation.
- **PPMS**: Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria (2018) — https://discovery.ucl.ac.uk/id/eprint/10041020 · Thompson et al. accepted manuscript, Panel 6 (one year progression plus two of three brain, spinal and CSF components) and Panel 3 recommendation for extra caution and CSF evaluation in progressive presentations.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-09-18 | revised | A newer 2024 revision was published in The Lancet Neurology. The historical 2017 map must not be presented as the current diagnostic standard or mixed with the new optic-nerve, CSF and MRI biomarker rules. | needs_review |
| 2018-02-01 | revised | 2017 revisions of the McDonald criteria published in Lancet Neurology. | confirmed |
| 2017-12-21 | published | The 2017 revisions of the McDonald criteria were published online by the International Panel on Diagnosis of Multiple Sclerosis. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mcdonald-2017 · API JSON: https://radcommons.laudos.ai/api/v1/systems/mcdonald-2017 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Modified Fisher — Modified Fisher CT scale for aneurysmal subarachnoid hemorrhage

> Two-axis admission noncontrast-CT descriptor combining thin versus thick subarachnoid blood with presence versus absence of intraventricular blood. It stratifies population risk of symptomatic vasospasm or delayed cerebral ischemia; it does not diagnose SAH, detect current vasospasm or prescribe treatment.

**Status:** current · **Organ:** Brain · **Issuing body:** Frontera et al. / neurocritical-care practice · **Version:** 2006 derivation; NINDS CDE operationalization and evidence reviewed through 2026 · **Year:** 2006

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Return the CT blood-burden axes, scan timing, definition provenance and uncertainty with the grade. Keep symptomatic vasospasm, angiographic vasospasm and DCI distinct, and never turn the category into a diagnosis or treatment order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, no SAH and no IVH | On an adequate early noncontrast head CT, neither subarachnoid blood nor intraventricular blood is visible. Both must be absent. A delayed or technically limited negative CT does not exclude earlier SAH, and isolated IVH without visible SAH is outside the canonical five-category map rather than grade 0. | If aneurysmal SAH is suspected or established, continue the emergency diagnostic, aneurysm-securing and neurocritical-care pathway regardless of this category. Grade 0 does not justify reassurance, reduced surveillance or withholding nimodipine; the scan timing, clinical state and complete workup govern care. | Only 20 of 1,355 derivation participants were grade 0, so the investigators pooled grades 0 and 1 as the odds-ratio reference and did not provide a stable grade-0 probability. Do not attach the grade-1 rate or a near-zero vasospasm/DCI risk to an individual grade-0 scan. | Frontera et al. 2006, PMID 16823296, Methods and Table 1 for no SAH/no IVH and the 20-patient grade-0 sample; Results for the pooled grade 0-1 reference. Hoh et al. 2023 AHA/ASA guidance for grade-independent emergency care. | ✓ |
| 1 | Grade 1, thin SAH without IVH | Focal or diffuse thin subarachnoid blood is present and no intraventricular blood is visible. Record the maximal clot thickness and site plus the named thin/thick rule: the original 2006 paper supplied no reproducible universal measurement, while the current NINDS CDE uses less than 1 mm for thin and leaves exactly 1 mm unresolved. | Use the grade as blood-burden risk context within specialist aSAH care, not as a low-risk discharge or treatment rule. Prompt aneurysm evaluation and treatment, early enteral nimodipine, euvolemia and appropriate clinical/DCI surveillance follow current guidance and the patient state rather than being switched on or off by grade 1. | Symptomatic vasospasm occurred in 24% of grade-1 participants in the 1,355-patient derivation cohort; grades 0-1 formed the odds-ratio reference. Across five later studies with crude grade data, the mean DCI frequency for grades 0-1 combined was 21% (SD 7; range 5-24%). These different endpoints and historical cohorts are not an individual forecast. | Frontera et al. 2006, Methods and Table 2, modified Fisher row 1 (thin SAH, no IVH; 24% symptomatic vasospasm); NINDS CDE ModFisherScale v3.1 for the less-than 1 mm operational wording; van der Steen et al. 2019, Modified Fisher results for DCI synthesis. | ✓ |
| 2 | Grade 2, thin SAH with IVH | Focal or diffuse thin subarachnoid blood is present together with unequivocal intraventricular blood in any ventricle. Bilateral lateral-ventricular involvement is not required. Preserve the thickness definition and return 2-versus-4 if the thin/thick boundary is unresolved. | Treat aneurysmal SAH and any hydrocephalus or ventricular obstruction on their own clinical merits. Grade 2 supports risk-aware monitoring but does not by itself order CSF diversion, angiography, induced hypertension or endovascular rescue; new deterioration requires direct evaluation for DCI, vasospasm, hydrocephalus and other causes. | In the derivation cohort, 33% developed symptomatic vasospasm; the crude odds ratio was 1.58 (95% CI 1.02-2.46) versus pooled grades 0-1. Later studies reported a mean 26% DCI frequency (SD 9; range 0-33%) for grade 2. Endpoint, era and cohort heterogeneity preclude using either as a bedside probability. | Frontera et al. 2006, Methods and Table 2, modified Fisher row 2 (thin SAH with IVH; 33%; OR 1.58, 95% CI 1.02-2.46); Melinosky et al. 2021 abstract for any-ventricle definition awareness; van der Steen et al. 2019 for DCI context. | ✓ |
| 3 | Grade 3, thick SAH without IVH | Focal or diffuse thick subarachnoid blood is present and no intraventricular blood is visible. The original derivation did not define a universal thickness measurement; the qualified NINDS CDE uses more than 1 mm. An exact or rounded 1 mm measurement remains ambiguous and should be returned as grade 1-versus-3 rather than forced. | Use the larger subarachnoid blood burden to inform specialist surveillance while following the complete aSAH pathway. The category does not diagnose current arterial narrowing or DCI and does not independently trigger prophylactic hemodynamic augmentation, which current AHA/ASA guidance advises against. | In the derivation cohort, 33% developed symptomatic vasospasm; the crude odds ratio was 1.59 (95% CI 1.14-2.22) versus pooled grades 0-1. Later studies reported a mean 30% DCI frequency (SD 9; range 5-36%) for grade 3. These are group-level, endpoint-specific summaries rather than an individual probability. | Frontera et al. 2006, Methods and Table 2, modified Fisher row 3 (thick SAH, no IVH; 33%; OR 1.59, 95% CI 1.14-2.22); NINDS CDE v3.1 for more-than 1 mm wording; van der Steen et al. 2019 for DCI context; Hoh et al. 2023 for hemodynamic boundaries. | ✓ |
| 4 | Grade 4, thick SAH with IVH | Focal or diffuse thick subarachnoid blood is present together with unequivocal blood in any ventricle. Record clot distribution, maximum thickness and every involved ventricle. Hydrocephalus, intraparenchymal hemorrhage and other blood compartments are important companion findings but do not alter the code. | This is the highest ordinal blood-burden category and warrants full specialist aSAH attention, but it is not a treatment order. Use examination trajectory and appropriate TCD, CTA, CT perfusion or angiography to evaluate suspected vasospasm/DCI; treat hydrocephalus and symptomatic DCI based on their actual findings and physiology. | In the derivation cohort, 40% developed symptomatic vasospasm; the crude odds ratio was 2.20 (95% CI 1.58-3.05) versus pooled grades 0-1. Later studies reported a mean 42% DCI frequency (SD 9; range 34-83%) for grade 4. The wide range and distinct endpoint make a fixed individual risk claim unsafe. | Frontera et al. 2006, Methods and Table 2, modified Fisher row 4 (thick SAH with IVH; 40%; OR 2.20, 95% CI 1.58-3.05); van der Steen et al. 2019 Modified Fisher results for DCI context; Hoh et al. 2023 AHA/ASA points 6-8 for surveillance and symptomatic-DCI care. | ✓ |

### Per-category citations
- **0**: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/ · Frontera et al. 2006, PMID 16823296, Methods and Table 1 for no SAH/no IVH and the 20-patient grade-0 sample; Results for the pooled grade 0-1 reference. Hoh et al. 2023 AHA/ASA guidance for grade-independent emergency care.
- **1**: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/ · Frontera et al. 2006, Methods and Table 2, modified Fisher row 1 (thin SAH, no IVH; 24% symptomatic vasospasm); NINDS CDE ModFisherScale v3.1 for the less-than 1 mm operational wording; van der Steen et al. 2019, Modified Fisher results for DCI synthesis.
- **2**: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/ · Frontera et al. 2006, Methods and Table 2, modified Fisher row 2 (thin SAH with IVH; 33%; OR 1.58, 95% CI 1.02-2.46); Melinosky et al. 2021 abstract for any-ventricle definition awareness; van der Steen et al. 2019 for DCI context.
- **3**: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/ · Frontera et al. 2006, Methods and Table 2, modified Fisher row 3 (thick SAH, no IVH; 33%; OR 1.59, 95% CI 1.14-2.22); NINDS CDE v3.1 for more-than 1 mm wording; van der Steen et al. 2019 for DCI context; Hoh et al. 2023 for hemodynamic boundaries.
- **4**: Frontera JA, Claassen J, Schmidt JM, et al.. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale (2006) — https://pubmed.ncbi.nlm.nih.gov/16823296/ · Frontera et al. 2006, Methods and Table 2, modified Fisher row 4 (thick SAH with IVH; 40%; OR 2.20, 95% CI 1.58-3.05); van der Steen et al. 2019 Modified Fisher results for DCI context; Hoh et al. 2023 AHA/ASA points 6-8 for surveillance and symptomatic-DCI care.

## Cross-references
- _shared boundary_ → [Fisher — Original Fisher CT grouping for aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/fisher.md) — Refinement of the original Fisher scale.
- _shared boundary_ → [Hunt-Hess — Hunt and Hess clinical grading of aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/hunt-hess.md) — CT blood burden grade complementing the Hunt and Hess clinical grade.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2006-07-01 | published | Frontera and colleagues published the five-category modified Fisher CT scale and its symptomatic-vasospasm derivation in 1,355 SAH trial participants. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/modified-fisher · API JSON: https://radcommons.laudos.ai/api/v1/systems/modified-fisher · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Rotterdam CT — Rotterdam CT score for traumatic brain injury

> Sums CT features to predict outcome after traumatic brain injury.

**Status:** current · **Organ:** Brain · **Issuing body:** Traumatic brain injury consensus · **Version:** 2005 · **Year:** 2005

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Score 1 | Total score of 1: the lowest category, produced when all four CT components score 0 (normal basal cisterns, no/minimal midline shift, no scoring of an epidural mass, no intraventricular or subarachnoid blood) plus the constant +1 added to every patient. | — | Lowest mortality category; reported ~3.2% (StatPearls TBI) and 5% 6-month mortality in the external-validation cohort. | StatPearls 'Traumatic Brain Injury' (NBK557861), Prognosis section (component point values and 'scores range from 1 to 6'); mortality from same section and from External Validation study PMC5602255 ('score 1, 5%'). | ✓ |
| 2 | Score 2 | Total score of 2: sum of the four weighted CT components equals 1, plus the constant +1. | — | ~7% 6-month mortality in the external-validation cohort. | StatPearls NBK557861, Prognosis section (component scoring); mortality from PMC5602255 ('score 2, 7%'). | ✓ |
| 3 | Score 3 | Total score of 3: sum of the four weighted CT components equals 2, plus the constant +1. | — | ~16% 6-month mortality in the external-validation cohort. | StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 3, 16%'). | ✓ |
| 4 | Score 4 | Total score of 4: sum of the four weighted CT components equals 3, plus the constant +1. | — | ~26% 6-month mortality in the external-validation cohort. | StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 4, 26%'). | ✓ |
| 5 | Score 5 | Total score of 5: sum of the four weighted CT components equals 4, plus the constant +1. | — | ~53% 6-month mortality in the external-validation cohort. | StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 5, 53%'). | ✓ |
| 6 | Score 6 | Total score of 6: the maximum, produced when the four CT components reach their worst values (basal cisterns absent = 2; midline shift >5 mm = 1; intraventricular/subarachnoid blood present = 1; epidural-mass component = 1) summing to 5, plus the constant +1. | — | Highest mortality category; ~61% 6-month mortality (external validation) and up to ~80% reported in StatPearls. | StatPearls NBK557861, Prognosis section ('a score of 6 can have mortalities of almost 80%'); 61% from PMC5602255 ('score 6, 61%'). | ✓ |

### Per-category citations
- **1**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls 'Traumatic Brain Injury' (NBK557861), Prognosis section (component point values and 'scores range from 1 to 6'); mortality from same section and from External Validation study PMC5602255 ('score 1, 5%').
- **2**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls NBK557861, Prognosis section (component scoring); mortality from PMC5602255 ('score 2, 7%').
- **3**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 3, 16%').
- **4**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 4, 26%').
- **5**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls NBK557861, Prognosis section; mortality from PMC5602255 ('score 5, 53%').
- **6**: Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with CT: the Rotterdam CT score (2005) — https://doi.org/10.1227/01.NEU.0000186013.63046.6B · StatPearls NBK557861, Prognosis section ('a score of 6 can have mortalities of almost 80%'); 61% from PMC5602255 ('score 6, 61%').


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/rotterdam-ct · API JSON: https://radcommons.laudos.ai/api/v1/systems/rotterdam-ct · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Scheltens MTA — Scheltens medial temporal atrophy visual rating scale

> Per-side 0-4 visual rating of medial temporal atrophy on a correctly oriented coronal T1-weighted image using choroid-fissure width, temporal-horn width and hippocampal height. It describes structural atrophy; it is neither a standalone Alzheimer diagnosis nor a treatment-eligibility rule, and every threshold must name its age, modality, cohort and side-combination protocol.

**Status:** current · **Organ:** Brain · **Issuing body:** Scheltens et al. / neuroradiology practice · **Version:** Original 1992 coronal MRI scale; interpretation evidence reviewed through 2024 · **Year:** 1992

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Report the original score bilaterally and preserve the protocol boundary. MTA is a structural sign, not a standalone etiologic diagnosis, risk calculator or management engine.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0 | No visually appreciable medial temporal atrophy on the scored side: the choroid fissure and temporal horn retain normal width and hippocampal height is preserved on an adequately oriented coronal T1-weighted image. Record right and left independently rather than using a single whole-patient zero. | No treatment or diagnostic closure follows from grade 0. If cognitive symptoms are present, continue the indicated clinical, neuropsychological, laboratory and complete imaging assessment and consider disease-specific biomarkers according to the actual question; low MTA does not end evaluation of early, young-onset or hippocampal-sparing disease. | Grade 0 is below proposed abnormal thresholds in published age protocols, but it does not exclude Alzheimer biology, another neurodegenerative process or future decline. The scale is a structural snapshot rather than a negative predictive guarantee, and risk cannot be estimated without age, symptoms, longitudinal change, other imaging findings and biomarker context. | Scheltens et al. 1992, PMID 1431963, original 0-4 bilateral coronal scale; Cotta Ramusino et al. 2019, PMC6690662, coronal rating plane and category 0; Jack et al. 2024, DOI 10.1002/alz.13859, biological AD diagnostic boundary. | ✓ |
| 1 | Grade 1 | Mild widening of the choroid fissure on the scored side, while the temporal horn remains normal in width and hippocampal height remains preserved. If the temporal horn or hippocampal height is already abnormal, reassess the grade-1-versus-2 boundary rather than scoring from the fissure alone. | Interpret grade 1 only after recording age, side, technique and the named cutoff protocol. It does not trigger therapy. In a symptomatic younger patient it may contribute to a pattern-based workup, whereas in an older adult it can fall within expected variation; integrate cognition, function, the full MRI pattern, vascular burden and biomarkers when clinically indicated. | A single grade 1 has no universal meaning. In the Claus 2017 memory-clinic CT protocol using the bilateral mean, at least 1.0 was proposed below age 65 but higher thresholds applied to older bands; other MRI cohorts use different cutoffs. Do not attach that protocol's sensitivity or specificity to one unilateral grade-1 observation. | Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-1 anatomy; Claus et al. 2017, PMC5491609, decade-specific CT bilateral-mean thresholds and performance; Molinder et al. 2021, PMC8305846, distinct MRI cohort thresholds. | ✓ |
| 2 | Grade 2 | Moderate widening of the choroid fissure together with mild widening of the temporal horn and mild loss of hippocampal height on the scored side. The three features are assessed as a pattern on the correct coronal plane; a numerical grade should not be manufactured when plane or coverage makes one axis unreliable. | Report side and asymmetry and interpret grade 2 against an explicitly named age, modality and bilateral-combination protocol. It can support clinically meaningful medial temporal atrophy in context but does not establish etiology or treatment eligibility. Correlate with cognitive phenotype, other regional atrophy, vascular disease and validated biomarkers as appropriate. | Grade 2 exceeds some younger-adult thresholds and meets the Claus CT bilateral-mean threshold for ages 75-84, but normal distributions shift with age and protocols differ. It increases concern for structural medial temporal neurodegeneration in an appropriate syndrome; it is not an individual probability of Alzheimer disease, conversion or treatment response. | Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-2 anatomy; Claus et al. 2017, age-specific CT mean-score thresholds; Molinder et al. 2021, validity across Alzheimer, vascular and mixed dementia; Park et al. 2021, DOI 10.1007/s00330-021-08227-8, heterogeneous group-level performance. | ✓ |
| 3 | Grade 3 | Marked widening of the choroid fissure, moderate enlargement of the temporal horn and moderate reduction of hippocampal height on the scored side. The side-specific score should be accompanied by the visible anatomic pattern and any asymmetry, not reduced to an unlabeled patient-level number. | Grade 3 warrants clinical correlation and usually strengthens the case for a structured cognitive-disorder evaluation when symptoms are present, but it does not specify a drug, prove Alzheimer pathology or independently qualify a patient for disease-modifying therapy. Evaluate alternative and mixed etiologies and the complete MRI rather than acting on the score alone. | This is substantial structural atrophy and exceeds many proposed cohort cutoffs, yet high MTA scores occur in non-Alzheimer conditions and in some very old cognitively healthy adults. A 2021 meta-analysis reported pooled 74 percent sensitivity and 88 percent specificity for Alzheimer disease versus healthy controls across thresholds, not a grade-3 posterior probability. | Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-3 anatomy and age-shifted normative distributions; Park et al. 2021, diagnostic meta-analysis; Jack et al. 2024, biological AD criteria and need to separate syndrome, neurodegeneration and pathology. | ✓ |
| 4 | Grade 4 | Severe or end-stage visual medial temporal atrophy on the scored side, with marked widening of the choroid fissure and temporal horn and severe loss of hippocampal height. Confirm that marked ventricular or sulcal enlargement is anatomically medial temporal and not chiefly distortion, resection, infarction or an oblique plane. | Communicate the severe side-specific structural finding and investigate its clinical and etiologic significance using symptoms, function, onset pattern, full MRI, vascular and structural lesions and relevant biomarkers. Grade 4 alone neither proves Alzheimer disease nor dictates treatment, prognosis, capacity, driving status or level of care. | Grade 4 represents the maximum visual atrophy category, but it is not synonymous with end-stage dementia or confirmed Alzheimer pathology. Normative work found that high scores become more frequent with advanced age, and marked medial temporal atrophy also has non-Alzheimer causes; prognosis requires clinical stage, longitudinal data, comorbidity and etiology. | Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-4 or end-stage visual pattern and normative age distributions; Molinder et al. 2021, heterogeneous etiologies and validity limits; Alzheimer's Association 2024 revised criteria for biological diagnosis. | ✓ |

### Per-category citations
- **0**: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967 · Scheltens et al. 1992, PMID 1431963, original 0-4 bilateral coronal scale; Cotta Ramusino et al. 2019, PMC6690662, coronal rating plane and category 0; Jack et al. 2024, DOI 10.1002/alz.13859, biological AD diagnostic boundary.
- **1**: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967 · Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-1 anatomy; Claus et al. 2017, PMC5491609, decade-specific CT bilateral-mean thresholds and performance; Molinder et al. 2021, PMC8305846, distinct MRI cohort thresholds.
- **2**: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967 · Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-2 anatomy; Claus et al. 2017, age-specific CT mean-score thresholds; Molinder et al. 2021, validity across Alzheimer, vascular and mixed dementia; Park et al. 2021, DOI 10.1007/s00330-021-08227-8, heterogeneous group-level performance.
- **3**: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967 · Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-3 anatomy and age-shifted normative distributions; Park et al. 2021, diagnostic meta-analysis; Jack et al. 2024, biological AD criteria and need to separate syndrome, neurodegeneration and pathology.
- **4**: Scheltens P, Leys D, Barkhof F, et al.. Atrophy of medial temporal lobes on MRI in Alzheimer's disease (Scheltens scale) (1992) — https://doi.org/10.1136/jnnp.55.10.967 · Scheltens et al. 1992 and Cotta Ramusino et al. 2019, grade-4 or end-stage visual pattern and normative age distributions; Molinder et al. 2021, heterogeneous etiologies and validity limits; Alzheimer's Association 2024 revised criteria for biological diagnosis.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1992-10-01 | published | Scheltens and colleagues published the bilateral 0-4 coronal MRI visual rating scale using choroid-fissure width, temporal-horn width and hippocampal height. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/scheltens-mta · API JSON: https://radcommons.laudos.ai/api/v1/systems/scheltens-mta · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Spetzler-Martin — Spetzler-Martin grading of brain arteriovenous malformations

> Grades brain AVM surgical risk by size, eloquence of adjacent brain, and venous drainage.

**Status:** current · **Organ:** Brain · **Issuing body:** Neurosurgical consensus · **Version:** 1986 · **Year:** 1986

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: MRI, Angiography
- Primary source: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return the numeric grade together with S/E/V components. Grade VI is a historical expert designation outside the arithmetic sum; the scale is a microsurgical-risk tool, not an automatic treatment rule.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I, numeric score 1 | Numeric total 1: a small nidus below 3 cm (S1), noneloquent adjacent brain (E0), and superficial venous drainage only (V0); the only valid component profile is S1E0V0. | Use grade I as one estimate of risk from open microsurgical resection and retain the S/E/V profile. The grade does not by itself choose observation, surgery, embolization or radiosurgery. | Lowest numeric microsurgical-risk grade in the scale. It predicts operative morbidity and mortality comparatively, not the untreated hemorrhage risk. | Spetzler and Martin 1986, PMID 3760956 abstract: grade I is small, superficial and noneloquent; CNS Clinical Neurosurgery 2011, Table 1: size, eloquence and drainage points. | ✓ |
| II | Grade II, numeric score 2 | Numeric total 2. Valid S/E/V profiles are S1E1V0, S1E0V1 or S2E0V0, where S1 is below 3 cm and S2 is 3-6 cm inclusive. | Use grade II as one estimate of risk from open microsurgical resection and report the actual S/E/V profile. The grade does not by itself choose a treatment modality. | Relatively low numeric microsurgical-risk grade, but different size, eloquence and drainage combinations can produce the same total and remain clinically relevant. | CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: S=1-3, E=0-1 and V=0-1; arithmetic profiles summing to 2. NCBI Bookshelf NBK531479, Spetzler-Martin section. | ✓ |
| III | Grade III, numeric score 3 | Numeric total 3. Valid profiles are S1E1V1, S2E1V0, S2E0V1 or S3E0V0; grade III is therefore anatomically heterogeneous and the component profile must accompany the total. | Use grade III as one estimate of open-microsurgical risk and preserve the S/E/V subtype for multidisciplinary planning. The numeric total alone does not select embolization or any other treatment. | Intermediate numeric microsurgical-risk grade whose risk is not uniform across its component profiles; it is not a measure of spontaneous hemorrhage risk. | CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: component points and additive grade; the four listed profiles are the complete arithmetic combinations summing to 3. | ✓ |
| IV | Grade IV, numeric score 4 | Numeric total 4. Valid profiles are S2E1V1, S3E1V0 or S3E0V1, combining a medium or large nidus with eloquence and/or deep venous drainage. | Treat grade IV as a high open-microsurgical-risk descriptor and retain the S/E/V profile. Final management requires individualized neurovascular review and is not dictated by the grade alone. | High numeric risk for morbidity and mortality from open microsurgical resection; the scale does not directly estimate embolization, radiosurgery or natural-history risk. | CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: component points and additive grade; NCBI Bookshelf NBK531479 states that perioperative risk increases with grade and does not necessarily transfer to other modalities. | ✓ |
| V | Grade V, numeric score 5 | Numeric total 5, the maximum additive score: large nidus above 6 cm (S3), eloquent adjacent brain (E1), and any deep venous drainage (V1), profile S3E1V1. | Treat grade V as the highest numeric open-microsurgical-risk descriptor and retain the S/E/V profile. Final management requires individualized neurovascular review and is not dictated by the grade alone. | Highest numeric microsurgical-risk grade. The original article characterizes grade V as large, deep and neurologically critical, without making it a patient-specific probability. | Spetzler and Martin 1986, PMID 3760956 abstract: grade V lesions are large, deep and in neurologically critical areas; CNS Clinical Neurosurgery 2011, Table 1: maximum profile S3E1V1. | ✓ |
| VI | Grade VI, historical non-numeric designation for an essentially inoperable AVM | Historical special designation from the original publication for an AVM judged essentially inoperable. Grade VI is an expert designation outside the 1-5 additive S/E/V calculation and cannot be generated by summing points. | Do not calculate grade VI from imaging points or treat the label as an automatic no-treatment command. If the historical designation is used, state that it is non-numeric and requires specialist neurovascular judgment. | The original designation represents operative concern beyond numeric grade V, but it supplies no separate quantitative risk estimate and does not measure natural-history hemorrhage risk. | Spetzler and Martin 1986, PMID 3760956 abstract: all AVMs were described in six grades and grade VI as essentially inoperable; NCBI Bookshelf NBK531479 distinguishes numeric grades I-V from the special grade VI designation. | ✓ |

### Per-category citations
- **I**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · Spetzler and Martin 1986, PMID 3760956 abstract: grade I is small, superficial and noneloquent; CNS Clinical Neurosurgery 2011, Table 1: size, eloquence and drainage points.
- **II**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: S=1-3, E=0-1 and V=0-1; arithmetic profiles summing to 2. NCBI Bookshelf NBK531479, Spetzler-Martin section.
- **III**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: component points and additive grade; the four listed profiles are the complete arithmetic combinations summing to 3.
- **IV**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · CNS Clinical Neurosurgery 2011, Table 1 reproduced from Spetzler and Martin: component points and additive grade; NCBI Bookshelf NBK531479 states that perioperative risk increases with grade and does not necessarily transfer to other modalities.
- **V**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · Spetzler and Martin 1986, PMID 3760956 abstract: grade V lesions are large, deep and in neurologically critical areas; CNS Clinical Neurosurgery 2011, Table 1: maximum profile S3E1V1.
- **VI**: Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations (1986) — https://doi.org/10.3171/jns.1986.65.4.0476 · Spetzler and Martin 1986, PMID 3760956 abstract: all AVMs were described in six grades and grade VI as essentially inoperable; NCBI Bookshelf NBK531479 distinguishes numeric grades I-V from the special grade VI designation.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1986-10-01 | published | Spetzler-Martin AVM grading proposed. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/spetzler-martin · API JSON: https://radcommons.laudos.ai/api/v1/systems/spetzler-martin · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# WFNS SAH — WFNS clinical grading of aneurysmal subarachnoid hemorrhage

> Bedside clinical severity grade derived from the post-resuscitation Glasgow Coma Scale and presence of a major focal neurologic deficit: 1 is GCS 15 without deficit; 2 and 3 share GCS 13-14 and are separated by absence versus presence of deficit; 4 is GCS 7-12; and 5 is GCS 3-6. It is not a CT blood-burden scale, an aneurysm-treatment selector, a futility rule or an individualized prognosis.

**Status:** current · **Organ:** Brain · **Issuing body:** World Federation of Neurosurgical Societies · **Version:** 1988 scale; current aSAH-care context reviewed through 2026 · **Year:** 1988

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Clinical
- Primary source: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Assign WFNS from a reliable clinical examination at a named timepoint. Preserve confounders and never turn a CT pattern or a poor clinical grade into an automatic treatment or futility decision.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | Glasgow Coma Scale total 15 with no major focal neurologic deficit, assessed at a named timepoint after initial resuscitation with examination reliability documented. | Use the grade for severity communication while activating current aneurysmal-SAH care. Identify and secure a ruptured aneurysm as early as feasible, preferably within 24 hours when appropriate; do not let grade 1 replace aneurysm anatomy, hydrocephalus, rebleeding risk or multidisciplinary planning. | This is the least clinically impaired WFNS category and is associated with more favorable group outcomes than higher grades, but it is not a patient-specific survival or functional-outcome probability and does not guarantee an uncomplicated course. | Drake et al., J Neurosurg 1988;68:985-986, DOI 10.3171/jns.1988.68.6.0985, original grade table; Rosen and Macdonald, PMC3621041, Table 3, grade 1; Hoh et al. 2023 and Vergouwen et al. 2026 for current care boundaries. | ✓ |
| 2 | Grade 2 | Glasgow Coma Scale total 13-14 with no major focal neurologic deficit. The absence of the deficit is the decisive distinction from grade 3 at the same GCS range. | Treat the numeral as clinical context, not a delay or intervention rule. Apply prompt specialized aneurysmal-SAH evaluation and aneurysm securing according to current guidance while addressing hydrocephalus, seizures, cardiopulmonary instability and other patient-specific factors. | Grade 2 carries greater clinical impairment than grade 1 in the ordinal scale, but no portable per-grade mortality or disability percentage follows from the code. Timing, reversible confounders and the complete hemorrhage and patient phenotype remain essential. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 2 row showing GCS 13-14 and major focal deficit absent; current-care sources as listed above. | ✓ |
| 3 | Grade 3 | Glasgow Coma Scale total 13-14 with a major focal neurologic deficit present, such as aphasia or hemiparesis when the examination reliably establishes it. | Do not translate grade 3 into a treatment threshold. Use the same urgent aneurysmal-SAH pathway and early aneurysm-treatment evaluation, while separately reporting the focal deficit, its possible mechanism, imaging findings and any reversible examination factors. | The focal deficit separates grade 3 from grade 2 and adds clinically important context, but the grade alone cannot determine the cause, reversibility, individual prognosis or benefit of a specific intervention. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 3 row showing GCS 13-14 and major focal deficit present; current-care sources as listed above. | ✓ |
| 4 | Grade 4 | Glasgow Coma Scale total 7-12, with major focal neurologic deficit either present or absent. The deficit does not move a patient out of this GCS-defined band. | Provide aggressive resuscitation, identify reversible causes of depressed examination and evaluate early aneurysm securing in a specialized center. Grade 4 is not a futility label and does not justify the historical practice of automatically postponing aneurysm treatment. | Grade 4 is a poor clinical grade associated with worse population outcomes than grades 1-3, yet patient outcome cannot be calculated from the numeral. Sedation, intubation, hydrocephalus, seizure, hypoxia, hypotension and assessment timing can materially alter observed grade and prognosis. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 4 row; AHA/ASA 2023 DOI 10.1161/STR.0000000000000436 and ESO/EANS/ESMINT 2026 PMC13151661 for current treatment context. | ✓ |
| 5 | Grade 5 | Glasgow Coma Scale total 3-6, with major focal neurologic deficit either present or absent, after documenting resuscitation state and all factors that limit or depress the examination. | Treat immediately reversible causes, use specialized neurocritical care and assess aneurysm securing and other interventions from the full clinical picture. Grade 5 alone neither establishes neurologic futility nor mandates withdrawal, delay or a particular procedural approach. | This is the most clinically impaired WFNS band and is associated with the least favorable cohort outcomes, but selected patients recover. Do not export single-center grade-5 outcome percentages to an individual or ignore confounding and trajectory. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 5 row; current AHA/ASA and ESO/EANS/ESMINT guidance for nonfutile contemporary care. | ✓ |

### Per-category citations
- **1**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al., J Neurosurg 1988;68:985-986, DOI 10.3171/jns.1988.68.6.0985, original grade table; Rosen and Macdonald, PMC3621041, Table 3, grade 1; Hoh et al. 2023 and Vergouwen et al. 2026 for current care boundaries.
- **2**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 2 row showing GCS 13-14 and major focal deficit absent; current-care sources as listed above.
- **3**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 3 row showing GCS 13-14 and major focal deficit present; current-care sources as listed above.
- **4**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 4 row; AHA/ASA 2023 DOI 10.1161/STR.0000000000000436 and ESO/EANS/ESMINT 2026 PMC13151661 for current treatment context.
- **5**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 5 row; current AHA/ASA and ESO/EANS/ESMINT guidance for nonfutile contemporary care.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-01-01 | revised | The joint ESO/EANS/ESMINT guideline supplied current European multidisciplinary care context without redefining the WFNS scale. | confirmed |
| 2023-05-22 | revised | The AHA/ASA aneurysmal-SAH guideline supplied current treatment-timing and neurocritical-care context; it did not change the five WFNS grade definitions or make poor grade a futility rule. | confirmed |
| 1988-06-01 | published | The WFNS committee published the five-grade GCS-plus-major-focal-deficit clinical scale for subarachnoid hemorrhage. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/wfns-sah · API JSON: https://radcommons.laudos.ai/api/v1/systems/wfns-sah · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# mTICI — Modified Treatment in Cerebral Infarction reperfusion grade

> Grades angiographic reperfusion after thrombectomy.

**Status:** current · **Organ:** Brain · **Issuing body:** Stroke imaging consensus · **Version:** 2013 · **Year:** 2013

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Angiography
- Primary source: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | No reperfusion | No perfusion: no antegrade flow beyond the site of occlusion. | Represents failed reperfusion; supports continued thrombectomy attempts/rescue strategies as the angiographic goal is at least mTICI 2b-3 (the procedural endpoint). | Failed reperfusion (unsuccessful); associated with the worst functional outcomes. | Almekhlafi et al., 'Not All "Successful" Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System,' PMC3971136, Table 1 / Methods, TICI 0 = 'No perfusion or anterograde flow beyond site of occlusion.' | ✓ |
| 1 | Penetration without perfusion | Penetration but not perfusion: contrast passes the initial obstruction but with only minimal filling of the distal (normal) territory. | Below the successful-reperfusion threshold; supports further thrombectomy passes/rescue toward the mTICI 2b-3 endpoint. | Considered unsuccessful reperfusion (minimal distal filling). | PMC3971136, Table 1 / Methods, TICI 1 = 'Penetration but not perfusion. Contrast penetration exists past the initial obstruction but with minimal filling of the normal territory.' | ✓ |
| 2a | Less than half reperfused | Partial perfusion with distal branch filling of less than half (<50%) of the previously occluded artery's territory. | Falls short of the successful threshold (mTICI 2b); supports additional thrombectomy attempts where feasible to reach >=50% territory reperfusion. | Partial / generally considered incomplete (unsuccessful) reperfusion (<50% territory). | PMC3971136, Table 1 / Methods, TICI 2a = 'Some perfusion with distal branch filling of <50% of territory visualized.' | ✓ |
| 2b | More than half reperfused | Substantial partial perfusion with distal branch filling of half or more (>=50%) of the occluded artery's territory, but short of complete. | Meets the conventional 'successful reperfusion' threshold (mTICI 2b-3); commonly accepted as an adequate procedural endpoint, though 2c/3 is increasingly pursued. | Threshold commonly used (together with 2c and 3) to define 'successful' reperfusion (>=50% territory). | PMC3971136, Table 1 / Methods, TICI 2b = 'Substantial perfusion with distal branch filling of >=50% of territory visualized.' | ✓ |
| 2c | Near complete | Near-complete perfusion: filling is essentially complete except for slow flow in a few distal cortical vessels, or the presence of small distal cortical emboli. | Successful reperfusion; combined mTICI 2c/3 is the proposed optimal angiographic target of mechanical thrombectomy for the best functional outcomes. | Intermediate-but-favourable category; combined 2c/3 is the proposed target of mechanical thrombectomy. | PMC3971136, Table 1 / Methods, TICI 2c = 'Near complete perfusion except for slow flow in a few distal cortical vessels, or presence of small distal cortical emboli.' | ✓ |
| 3 | Complete reperfusion | Complete perfusion: normal filling of all distal branches of the previously occluded vessel. | Optimal angiographic endpoint of thrombectomy; complete reperfusion, no further reperfusion attempts needed. | Best angiographic outcome; complete reperfusion, associated with the best functional outcomes. | PMC3971136, Table 1 / Methods, TICI 3 = 'Complete perfusion with normal filling of all distal branches.' | ✓ |

### Per-category citations
- **0**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · Almekhlafi et al., 'Not All "Successful" Angiographic Reperfusion Patients Are an Equal Validation of a Modified TICI Scoring System,' PMC3971136, Table 1 / Methods, TICI 0 = 'No perfusion or anterograde flow beyond site of occlusion.'
- **1**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · PMC3971136, Table 1 / Methods, TICI 1 = 'Penetration but not perfusion. Contrast penetration exists past the initial obstruction but with minimal filling of the normal territory.'
- **2a**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · PMC3971136, Table 1 / Methods, TICI 2a = 'Some perfusion with distal branch filling of <50% of territory visualized.'
- **2b**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · PMC3971136, Table 1 / Methods, TICI 2b = 'Substantial perfusion with distal branch filling of >=50% of territory visualized.'
- **2c**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · PMC3971136, Table 1 / Methods, TICI 2c = 'Near complete perfusion except for slow flow in a few distal cortical vessels, or presence of small distal cortical emboli.'
- **3**: Zaidat OO, Yoo AJ, Khatri P, et al.. Recommendations on angiographic revascularization grading standards (mTICI) (2013) — https://doi.org/10.1161/STROKEAHA.113.001972 · PMC3971136, Table 1 / Methods, TICI 3 = 'Complete perfusion with normal filling of all distal branches.'


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mtici · API JSON: https://radcommons.laudos.ai/api/v1/systems/mtici · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# BI-RADS — Breast Imaging Reporting and Data System, 5th edition

> Final assessment categories and management for mammography, breast ultrasound, and breast MRI.

**Status:** current · **Organ:** Breast · **Issuing body:** American College of Radiology · **Version:** 5th edition · **Year:** 2013

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Mammography, US, MRI
- Primary source: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Incomplete, need additional imaging | Incomplete assessment; the workup cannot yet be finalized and more information is needed. | Obtain additional imaging (e.g., extra mammographic views or ultrasound) and/or retrieve prior studies for comparison before assigning a final category. | — | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS for mammography and ultrasound 2013, category 0 | ✓ |
| 1 | Negative | Negative study; no masses, architectural distortion, or suspicious calcifications identified. | Continue routine age-appropriate screening. | Essentially 0% likelihood of malignancy. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 1 | ✓ |
| 2 | Benign | Benign finding(s) described (e.g., calcified fibroadenoma, fat-containing lesion, intramammary node, post-surgical change). | Continue routine age-appropriate screening; no specific follow-up of the finding required. | Essentially 0% likelihood of malignancy. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 2 | ✓ |
| 3 | Probably benign | Probably benign finding; expected to be benign with very high confidence. | Short-interval (initially 6-month) follow-up, then continued surveillance (e.g., at 12 months); if stable over the surveillance period the finding may be downgraded to category 2. | Greater than 0% but no more than 2% likelihood of malignancy. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 3 ("less than a 2% risk of malignancy") | ✓ |
| 4 | Suspicious | Suspicious finding that does not have the classic appearance of malignancy but warrants tissue sampling. | Tissue diagnosis (image-guided needle biopsy) should be considered; category may be subdivided into 4A, 4B, 4C. | Wide range of likelihood of malignancy spanning greater than 2% to less than 95%. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 4; PMC6413875 Introduction ("Category 4 covers a wide range of likelihood of malignancy, from more than 2% to less than 95%") | ✓ |
| 4A | Low suspicion for malignancy | Suspicious breast finding in the low-suspicion subdivision of category 4, corresponding to a greater than 2% but no more than 10% likelihood of malignancy. | Tissue diagnosis (image-guided biopsy) recommended. | Greater than 2% to no more than 10% likelihood of malignancy. | BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4A > 2% to ≤ 10%") | ✓ |
| 4B | Moderate suspicion for malignancy | Suspicious breast finding in the moderate-suspicion subdivision of category 4, corresponding to a greater than 10% but no more than 50% likelihood of malignancy. | Tissue diagnosis (image-guided biopsy) recommended. | Greater than 10% to no more than 50% likelihood of malignancy. | BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4B > 10% to ≤ 50%") | ✓ |
| 4C | High suspicion for malignancy | High suspicion within category 4 (but not the classic appearance of malignancy). | Tissue diagnosis (image-guided biopsy) recommended. | Greater than 50% to less than 95% likelihood of malignancy. | BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4C > 50% to < 95%") | ✓ |
| 5 | Highly suggestive of malignancy | Highly suggestive of malignancy with the classic appearance of breast cancer. | Appropriate action should be taken (tissue diagnosis / definitive management). | At least 95% likelihood of malignancy. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 5 (">95% likelihood of malignancy") | ✓ |
| 6 | Known biopsy proven malignancy | Biopsy-proven malignancy already established by prior tissue diagnosis. | Used to monitor a known cancer before/after definitive treatment (e.g., after incomplete excision or during neoadjuvant chemotherapy). | Known (biopsy-proven) malignancy. | BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 6 | ✓ |

### Per-category citations
- **0**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS for mammography and ultrasound 2013, category 0
- **1**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 1
- **2**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 2
- **3**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 3 ("less than a 2% risk of malignancy")
- **4**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 4; PMC6413875 Introduction ("Category 4 covers a wide range of likelihood of malignancy, from more than 2% to less than 95%")
- **4A**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4A > 2% to ≤ 10%")
- **4B**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4B > 10% to ≤ 50%")
- **4C**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS 5th edition category 4 subdivisions; PMC6413875 Introduction and Table 2 ("4C > 50% to < 95%")
- **5**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 5 (">95% likelihood of malignancy")
- **6**: D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System, 5th edition (2013) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Bi-Rads · BI-RADS assessment categories (5th edition); radiologyassistant.nl BI-RADS 2013, category 6

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-23 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-21 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-20 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-19 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-18 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-17 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-16 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-15 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2013-01-01 | published | BI-RADS Atlas 5th edition published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bi-rads-2013 · API JSON: https://radcommons.laudos.ai/api/v1/systems/bi-rads-2013 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# CAC — Coronary artery calcium (Agatston) categories

> Risk categories based on the Agatston coronary artery calcium score.

**Status:** current · **Organ:** Cardiac · **Issuing body:** Cardiac imaging consensus · **Version:** 1990 · **Year:** 1990

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Agatston AS, Janowitz WR, Hildner FJ, et al.. Quantification of coronary artery calcium using ultrafast computed tomography (1990) — https://doi.org/10.1016/0735-1097(90)90282-T
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | No identifiable calcium | Agatston score of 0: no identifiable calcified coronary plaque on the gated noncontrast CT (no calcific lesions reaching the detection threshold across the proximal coronary arteries). | With a score of 0 and no other major risk factors, statin therapy is generally not indicated; the finding supports deferring or withholding pharmacologic prevention and reassessing later. (Final decisions follow ASCVD-prevention guidelines.) | 'No identifiable disease'; extremely low risk of cardiovascular events. A zero score is described as the most powerful negative predictor (the 'power of zero') in asymptomatic patients; the original 1990 cohort reported a negative predictive value of 94-100% for clinical coronary disease across the 40-69y groups. | Severity label, risk interpretation and statin guidance from StatPearls 'Coronary Artery Calcification' (NBK519037), CAC interpretation / clinical-significance and management sections ('0 = No identifiable disease'; 'power of zero'; 'CAC = 0 with no other risk factors: no statin indicated'). NPV figure from Agatston 1990 abstract. | ✓ |
| 1-99 | Mild | Agatston score 1-99: a small amount of calcified coronary plaque (mild calcified plaque burden). | Statin therapy is generally initiated in patients older than ~55 years; in younger patients (<55) statin may be withheld with reassessment in ~3-5 years. | 'Mild disease' / mild calcified plaque burden, conferring modestly increased cardiovascular risk above a zero score. | StatPearls NBK519037, CAC severity bands and management ('1 to 99 = Mild disease'; 'CAC 1-99, age >55: initiate statin'; 'CAC 1-99, age <55: statin can be withheld; reassess in 3-5 years'). | ✓ |
| 100-399 | Moderate | Agatston score 100-399: a moderate amount of calcified coronary plaque (moderate calcified plaque burden). | Statin therapy is recommended (CAC over 100 generally warrants statin). | 'Moderate disease' / moderate calcified plaque burden, with progressively elevated cardiovascular risk relative to lower bands. | StatPearls NBK519037, CAC severity bands and management ('100 to 399 = Moderate disease'; 'CAC >100: statin therapy recommended'). | ✓ |
| >=400 | Severe | Agatston score 400 or higher: an extensive amount of calcified coronary plaque (severe calcified plaque burden). | Statin therapy is recommended (score over 100 warrants statin); a score over 400 is widely regarded as severe and may prompt further cardiovascular evaluation. | 'Severe disease' / extensive calcified plaque burden; a CAC over 400 is associated with worsened clinical outcomes and correlates with advanced/obstructive coronary disease. | StatPearls NBK519037, CAC severity bands, clinical-significance and management ('Greater than 400 = Severe Disease'; 'A CAC score over 400 is associated with worsened clinical outcomes'; 'CAC >100: statin therapy recommended'). | ✓ |

### Per-category citations
- **0**: Agatston AS, Janowitz WR, Hildner FJ, et al.. Quantification of coronary artery calcium using ultrafast computed tomography (1990) — https://doi.org/10.1016/0735-1097(90)90282-T · Severity label, risk interpretation and statin guidance from StatPearls 'Coronary Artery Calcification' (NBK519037), CAC interpretation / clinical-significance and management sections ('0 = No identifiable disease'; 'power of zero'; 'CAC = 0 with no other risk factors: no statin indicated'). NPV figure from Agatston 1990 abstract.
- **1-99**: Agatston AS, Janowitz WR, Hildner FJ, et al.. Quantification of coronary artery calcium using ultrafast computed tomography (1990) — https://doi.org/10.1016/0735-1097(90)90282-T · StatPearls NBK519037, CAC severity bands and management ('1 to 99 = Mild disease'; 'CAC 1-99, age >55: initiate statin'; 'CAC 1-99, age <55: statin can be withheld; reassess in 3-5 years').
- **100-399**: Agatston AS, Janowitz WR, Hildner FJ, et al.. Quantification of coronary artery calcium using ultrafast computed tomography (1990) — https://doi.org/10.1016/0735-1097(90)90282-T · StatPearls NBK519037, CAC severity bands and management ('100 to 399 = Moderate disease'; 'CAC >100: statin therapy recommended').
- **>=400**: Agatston AS, Janowitz WR, Hildner FJ, et al.. Quantification of coronary artery calcium using ultrafast computed tomography (1990) — https://doi.org/10.1016/0735-1097(90)90282-T · StatPearls NBK519037, CAC severity bands, clinical-significance and management ('Greater than 400 = Severe Disease'; 'A CAC score over 400 is associated with worsened clinical outcomes'; 'CAC >100: statin therapy recommended').

## Cross-references
- _shared boundary_ → [CAD-RADS — Coronary Artery Disease Reporting and Data System v2.0](https://radcommons.laudos.ai/systems/cad-rads.md) — Calcium scoring complements CAD-RADS stenosis grading on coronary CT.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/cac-agatston · API JSON: https://radcommons.laudos.ai/api/v1/systems/cac-agatston · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# CAD-RADS — Coronary Artery Disease Reporting and Data System v2.0

> Standardized reporting of coronary CT angiography by maximal stenosis, plaque burden, ischemia and modifiers.

**Status:** current · **Organ:** Cardiac · **Issuing body:** SCCT / ACC / ACR / NASCI · **Version:** 2.0 · **Year:** 2022

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Compose stenosis, plaque burden, then modifiers. N may replace the numeric stenosis category or follow it depending on diagnostic segments; use the cited outcome criteria rather than inferring a code.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | 0 percent, no plaque | 0% maximal coronary stenosis - no plaque and no luminal stenosis (absence of coronary atherosclerosis). | Reassurance; consideration of non-atherosclerotic causes of symptoms; preventive measures / risk-factor management as clinically appropriate. | No coronary atherosclerosis. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 0 row), per-patient maximal stenosis | ✓ |
| 1 | 1 to 24 percent, minimal | 1-24% maximal coronary stenosis - minimal stenosis or plaque with no stenosis. | Emphasis on preventive therapy and risk-factor modification; generally no further cardiac testing for the stenosis itself. | Minimal coronary stenosis. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 1 row) | ✓ |
| 2 | 25 to 49 percent, mild | 25-49% maximal coronary stenosis - mild stenosis. | Preventive therapy and risk-factor modification; considered non-obstructive, so no specific ischemia work-up is mandated for the stenosis alone. | Mild, non-obstructive coronary stenosis. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 2 row) | ✓ |
| 3 | 50 to 69 percent, moderate | 50-69% maximal coronary stenosis - moderate stenosis. | Consideration of functional/ischemia assessment (e.g. CT-FFR, myocardial CT perfusion, stress testing) or invasive coronary angiography (ICA) when ischemia evaluation is needed; preventive therapy. | Moderate stenosis, potentially obstructive. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 3 row) | ✓ |
| 4A | 70 to 99 percent in 1 or 2 vessels, severe | 70-99% maximal coronary stenosis (severe) in 1 or 2 vessels, without left main involvement or 3-vessel obstructive disease. | Consideration of ICA and/or functional imaging (e.g. CT-FFR, myocardial CT perfusion, stress testing); preventive therapy and risk-factor modification. | Severe, obstructive stenosis limited to 1 or 2 vessels. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 4A row), per-patient maximal stenosis | ✓ |
| 4B | Left main 50 percent or more, or 3-vessel obstructive disease | Left main stenosis >=50% OR 3-vessel obstructive disease (>=70% stenosis in each of three vessels). | ICA recommended, with possible revascularization, particularly in symptomatic patients; this higher-risk anatomy is managed more aggressively than 4A. | Severe stenosis with higher-risk anatomy (left main or 3-vessel obstructive disease). | CAD-RADS 2.0 stenosis categories table (CAD-RADS 4B row), per-patient maximal stenosis | ✓ |
| 5 | 100 percent, total occlusion | 100% stenosis - total coronary occlusion of at least one coronary artery (i.e. >99% / complete occlusion). | Consideration of ICA and/or viability assessment; evaluate whether the occlusion is acute versus chronic and assess collateralization, guiding possible revascularization. | Total coronary occlusion. | CAD-RADS 2.0 stenosis categories table (CAD-RADS 5 row) | ✓ |
| P1 | Plaque burden P1, mild | Mild overall coronary plaque burden on a per-patient basis: CAC 1-100; SIS <=2; or visual estimation of a mild amount of plaque in 1-2 vessels. CAD-RADS 0 denotes no plaque, so P0 is not used. | Report P1 after the stenosis category and interpret it with the full impression and clinical context. CAD-RADS 2.0 does not define an absolute treatment threshold from the P category alone. | Mild total coronary plaque burden; plaque burden contributes prognostic information beyond stenosis severity alone. | CAD-RADS 2.0 section 3.2.1 and Table 2 (P1 row); Tables 4-5 for management context | ✓ |
| P2 | Plaque burden P2, moderate | Moderate overall coronary plaque burden on a per-patient basis: CAC 101-300; SIS 3-4; or visual estimation of a moderate amount of plaque in 1-2 vessels or a mild amount in 3 vessels. | Report P2 after the stenosis category. A higher plaque burden may support more intensive preventive therapy consideration, but CAD-RADS 2.0 states that P categories are not absolute treatment thresholds and should be integrated with the impression and clinical context. | Moderate total coronary plaque burden; increasing plaque burden is associated with increasing cardiovascular risk independently of stenosis severity. | CAD-RADS 2.0 section 3.2.1 and Table 2 (P2 row); Tables 4-5 for management context | ✓ |
| P3 | Plaque burden P3, severe | Severe overall coronary plaque burden on a per-patient basis: CAC 301-999; SIS 5-7; or visual estimation of a moderate amount of plaque in 3 vessels or a severe amount in 1 vessel. | Report P3 after the stenosis category. A higher plaque burden may support more intensive preventive therapy consideration, but CAD-RADS 2.0 states that P categories are not absolute treatment thresholds and should be integrated with the impression and clinical context. | Severe total coronary plaque burden; increasing plaque burden is associated with increasing cardiovascular risk independently of stenosis severity. | CAD-RADS 2.0 section 3.2.1 and Table 2 (P3 row); Tables 4-5 for management context | ✓ |
| P4 | Plaque burden P4, extensive | Extensive overall coronary plaque burden on a per-patient basis: CAC >1000; SIS >=8; or visual estimation of a severe amount of plaque in 2-3 vessels. | Report P4 after the stenosis category. A higher plaque burden may support more intensive preventive therapy consideration, but CAD-RADS 2.0 states that P categories are not absolute treatment thresholds and should be integrated with the impression and clinical context. | Extensive total coronary plaque burden; increasing plaque burden is associated with increasing cardiovascular risk independently of stenosis severity. | CAD-RADS 2.0 section 3.2.1 and Table 2 (P4 row); Tables 4-5 for management context | ✓ |
| N | Modifier N, non-diagnostic study | Non-diagnostic study or segment. If a diagnostic segment contains stenosis >=50%, retain the numeric CAD-RADS category and append N; if interpretable segments show at most 25-49% stenosis and at least one segment >1.5 mm is non-interpretable, N replaces the numeric category. Add P when total plaque burden remains reliably assessable. | Further evaluation is required when N replaces the numeric category because significant stenosis cannot be reliably excluded. When a diagnostic segment already establishes CAD-RADS >=3, append N and base downstream considerations on the demonstrated disease plus the residual uncertainty. | N represents diagnostic uncertainty rather than a stenosis-severity or event-risk grade. | CAD-RADS 2.0 section 3.3.1 (Modifier N) and Figures 11-12 | ✓ |
| HRP | Modifier HRP, high-risk plaque | Add HRP when a single coronary plaque clearly demonstrates at least 2 high-risk features: positive remodeling (remodeling index >1.1), low-attenuation plaque (<30 HU), spotty calcification, or napkin-ring sign. Describe the specific features in the report text. | Do not use HRP in isolation to mandate invasive angiography. Integrate symptoms, stenosis, plaque burden, ischemia testing and the full clinical context; more aggressive preventive management may be considered in appropriate patients. | HRP features are associated with higher risk of acute coronary syndrome, future adverse cardiovascular events and lesion-specific ischemia, but their positive predictive value is modest when considered alone. | CAD-RADS 2.0 section 3.3.4 (High-risk plaque), Figures 15-16 and management discussion | ✓ |
| I+ | Modifier I+, positive ischemia | Positive lesion-specific ischemia: CT-FFR <=0.75 in a vessel large enough for PCI, or myocardial CT perfusion showing reversible ischemia or peri-infarct ischemia. | In a symptomatic patient and an appropriate revascularization context, I+ may support consideration of invasive coronary angiography; integrate lesion location, symptoms, anatomy and all available imaging or stress-test findings. | Imaging evidence of lesion-specific or myocardial inducible ischemia; this modifier does not replace the anatomic CAD-RADS category. | CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I+) | ✓ |
| I- | Modifier I-, negative ischemia | Negative lesion-specific ischemia: CT-FFR >0.80, or myocardial CT perfusion with no inducible ischemia. A fixed prior infarct is documented in the impression rather than treated as inducible ischemia. | When concordant with the anatomy and clinical context, I- may support deferral of invasive coronary angiography; it does not remove the need for preventive management indicated by plaque or stenosis. | No imaging evidence of inducible ischemia on the performed CT-based functional test; this is not equivalent to absence of coronary atherosclerotic risk. | CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I-) | ✓ |
| I+/- | Modifier I+/-, borderline or indeterminate ischemia | Borderline or indeterminate ischemia: lesion-specific CT-FFR 0.76-0.80, or myocardial CT perfusion that is borderline or inconclusive for inducible ischemia. | Do not convert I+/- into a binary decision. Further decisions depend on lesion location, symptom severity, anatomy and, for CT-FFR, the trans-lesional gradient; CAD-RADS 2.0 notes a delta CT-FFR >0.12 as significant context. | Indeterminate functional significance; residual uncertainty must be stated explicitly. | CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I+/-) | ✓ |
| S | Modifier S, coronary stent present | Add S when at least one coronary stent is present anywhere in the coronary system. Grade in-stent stenosis using the same stenosis bands as native coronary arteries. | S is a structural modifier, not a standalone management category; management follows the stenosis category, plaque burden, symptoms and clinical context. | Presence of a coronary stent; S alone is not a disease-severity or event-risk grade. | CAD-RADS 2.0 section 3.3.2 (Modifier S) and Figure 13 | ✓ |
| G | Modifier G, coronary bypass graft present | Add G when at least one coronary bypass graft is present. Do not count a native stenosis proximal to a fully patent graft for CAD-RADS coding; assess grafts and native segments distal to and including the anastomosis. Assess plaque burden across native arteries and grafts together. | G is a structural modifier. Further management depends on stenosis or occlusion in the evaluated grafts and eligible native segments, plus symptoms and clinical context. | Presence of coronary bypass grafting; G alone is not a disease-severity or event-risk grade. | CAD-RADS 2.0 section 3.3.3 (Modifier G) and Figure 14 | ✓ |
| E | Modifier E, non-atherosclerotic exception | Add E at the end of the CAD-RADS code for a non-atherosclerotic coronary abnormality or narrowing, including dissection, anomalous origin, aneurysm or pseudoaneurysm, vasculitis, fistula, extrinsic compression, arteriovenous malformation or another exception. The numeric category alone may not capture the abnormality. | Use disease-specific management considerations and/or subspecialty referral; do not treat the atherosclerotic CAD-RADS category as a complete management description for an E case. | Non-atherosclerotic coronary pathology whose risk is not represented by the atherosclerotic stenosis category alone. | CAD-RADS 2.0 Table 3 and section 3.3.6 (Modifier E) | ✓ |

### Per-category citations
- **0**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 0 row), per-patient maximal stenosis
- **1**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 1 row)
- **2**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 2 row)
- **3**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 3 row)
- **4A**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 4A row), per-patient maximal stenosis
- **4B**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 4B row), per-patient maximal stenosis
- **5**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 stenosis categories table (CAD-RADS 5 row)
- **P1**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.2.1 and Table 2 (P1 row); Tables 4-5 for management context
- **P2**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.2.1 and Table 2 (P2 row); Tables 4-5 for management context
- **P3**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.2.1 and Table 2 (P3 row); Tables 4-5 for management context
- **P4**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.2.1 and Table 2 (P4 row); Tables 4-5 for management context
- **N**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.1 (Modifier N) and Figures 11-12
- **HRP**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.4 (High-risk plaque), Figures 15-16 and management discussion
- **I+**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I+)
- **I-**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I-)
- **I+/-**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.5 and Tables 6-7 (ischemia modifier I+/-)
- **S**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.2 (Modifier S) and Figure 13
- **G**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 section 3.3.3 (Modifier G) and Figure 14
- **E**: Cury RC, Leipsic J, Abbara S, et al.. CAD-RADS 2.0: Coronary Artery Disease Reporting and Data System (2022) — https://doi.org/10.1016/j.jcct.2022.07.002 · CAD-RADS 2.0 Table 3 and section 3.3.6 (Modifier E)

## Cross-references
- _shared boundary_ → [CAC — Coronary artery calcium (Agatston) categories](https://radcommons.laudos.ai/systems/cac-agatston.md) — Coronary CT: CAD-RADS grades luminal stenosis while the calcium score quantifies calcified plaque burden.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2022-07-01 | revised | CAD-RADS 2.0 released, updating the 2016 system. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/cad-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/cad-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# TIMI flow — Original TIMI epicardial coronary flow grade

> Per-vessel, per-timepoint qualitative grade of epicardial coronary contrast entry, distal-bed opacification and clearance on invasive angiography. It is not the TIMI ACS risk score, TIMI myocardial perfusion grade, myocardial blush grade, corrected TIMI frame count or cerebral mTICI, and it cannot diagnose the mechanism, quantify tissue perfusion, select therapy or predict an individual's outcome by itself.

**Status:** current · **Organ:** Cardiac · **Issuing body:** TIMI Study Group · **Version:** 1985 original; 1996 corrected frame-count companion; 1999 three-cycle drift guard; 2025 ACS care boundary · **Year:** 1985

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Angiography
- Primary source: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Always bind the grade to artery and timepoint. It describes epicardial contrast flow only; mechanism, tissue perfusion, clinical risk and management are separate outputs.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, no perfusion | Original TIMI grade 0, no perfusion: no antegrade contrast flow is seen beyond the point of epicardial coronary occlusion in the named artery at the stated angiographic timepoint. Collateral filling is recorded separately and does not convert absent antegrade culprit flow into a higher grade. | Treat this as an urgent angiographic observation in its ACS or procedural context and determine whether the cause is acute thrombotic occlusion, chronic occlusion, dissection, spasm, embolus, another mechanical lesion or technical injection failure. The numeral alone cannot select wire crossing, thrombectomy, stenting, medication, surgery or futility. | Absent antegrade flow has been associated with worse group outcomes in historical reperfusion cohorts, especially when persistent after treatment, but grade, artery, pre/post-intervention timepoint, shock, infarct burden and tissue perfusion must be integrated. Do not attach an old cohort mortality percentage to an individual. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 0; Rao et al. 2025 ACS guideline, DOI 10.1016/j.jacc.2024.11.009, syndrome/revascularization context; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, qualitative versus quantitative flow boundary. | ✓ |
| 1 | Grade 1, penetration without perfusion | Original TIMI grade 1, penetration without perfusion: contrast passes beyond the obstruction but hangs up and fails to opacify the entire distal coronary bed during the cine run. Complete distal-bed filling is the decisive grade-1 versus grade-2 boundary. | Assess the persistent obstruction and procedural context, injection adequacy, thrombus, dissection, spasm, distal embolization and collaterals. Grade 1 signals ineffective antegrade distal perfusion but does not itself prescribe another device pass, a drug or an endpoint decision. | Grade 1 represents severely impaired epicardial flow and historically clusters with poor reperfusion, but it is not a calibrated personal prognosis and must not be pooled with grade 0 unless a cited study prespecified that analysis. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original penetration-without-perfusion definition; Gibson et al. 1999, PMID 10347349, preservation of original definitions; 2025 ACC/AHA multisociety ACS guideline for current care context. | ✓ |
| 2 | Grade 2, partial perfusion | Original TIMI grade 2, partial perfusion: contrast passes the obstruction and opacifies the entire distal coronary bed, but either distal entry or clearance is perceptibly slower than flow proximal to the obstruction or in a comparable uninvolved bed. A patent-looking vessel is not grade 3 unless both entry and washout are normal-reference prompt. | Investigate residual epicardial obstruction, thrombus, dissection, spasm, distal embolization, microvascular no-reflow, hemodynamics and technical factors. Post-PCI grade 2 can mark suboptimal flow, but mechanism-specific action belongs to the interventional team and current ACS pathway rather than to the grade itself. | Grade 2 is complete distal filling with delayed kinetics, not normal flow. Historical cohorts associate persistent grade 2 with worse outcomes than grade 3, but the association varies by timepoint and era and cannot be converted into an individual mortality, infarct-size or myocardial-salvage estimate. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 2 entry-or-clearance definition; Gibson et al. 1996, PMID 8598078, CTFC continuous companion; Rao et al. 2025, DOI 10.1016/j.jacc.2024.11.009. | ✓ |
| 3 | Grade 3, complete perfusion | Original TIMI grade 3, complete perfusion: antegrade contrast enters the distal bed as promptly as it enters the bed proximal to the obstruction or a comparable uninvolved artery, and clears from the involved bed just as rapidly. Do not substitute the nonoriginal shortcut of vessel opacification within fewer than three cardiac cycles. | Record grade 3 as normal epicardial visual flow at that artery/timepoint while still assessing residual stenosis, thrombus, dissection, myocardial blush or TMPG, ST resolution, ventricular function and clinical status. Grade 3 is neither a discharge criterion nor proof that no-reflow, infarction or incomplete revascularization is absent. | Grade 3 has the most favorable epicardial-flow association in reperfusion cohorts, but tissue-level microvascular obstruction and adverse outcomes can persist. It cannot supply a personal prognosis, prove myocardial salvage or erase the presenting ACS risk. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 3; Gibson et al. 1999, DOI 10.1016/S0002-8703(99)70380-7, original wording and approximately 10 percentage-point overcall from the three-cycle shortcut; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, CTFC heterogeneity within visual grades. | ✓ |

### Per-category citations
- **0**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 0; Rao et al. 2025 ACS guideline, DOI 10.1016/j.jacc.2024.11.009, syndrome/revascularization context; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, qualitative versus quantitative flow boundary.
- **1**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original penetration-without-perfusion definition; Gibson et al. 1999, PMID 10347349, preservation of original definitions; 2025 ACC/AHA multisociety ACS guideline for current care context.
- **2**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 2 entry-or-clearance definition; Gibson et al. 1996, PMID 8598078, CTFC continuous companion; Rao et al. 2025, DOI 10.1016/j.jacc.2024.11.009.
- **3**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 3; Gibson et al. 1999, DOI 10.1016/S0002-8703(99)70380-7, original wording and approximately 10 percentage-point overcall from the three-cycle shortcut; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, CTFC heterogeneity within visual grades.

## Cross-references
- _shared boundary_ → [mTICI — Modified Treatment in Cerebral Infarction reperfusion grade](https://radcommons.laudos.ai/systems/mtici.md) — TIMI grades qualitative epicardial coronary flow by distal entry, complete bed filling and clearance. mTICI grades cerebral-territory reperfusion after stroke treatment. Similar numerals and wording do not create a valid crosswalk.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-02-27 | revised | The current ACC/AHA multisociety ACS guideline supplies syndrome and revascularization management context; it does not turn a TIMI flow numeral into a standalone treatment algorithm. | confirmed |
| 1999-06-01 | revised | The TIMI Study Group documented method drift: defining grade 3 as transit within three cardiac cycles overcalled normal flow by about ten percentage points compared with the original normal-reference definition. | confirmed |
| 1996-03-01 | revised | The corrected TIMI frame count added a separate continuous, vessel- and frame-rate-controlled companion measurement; it did not replace or numerically redefine the visual grade. | confirmed |
| 1985-04-04 | published | The TIMI Study Group published the original four qualitative grades of epicardial coronary flow in the phase-I trial report. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/timi-flow · API JSON: https://radcommons.laudos.ai/api/v1/systems/timi-flow · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# CO-RADS — COVID-19 Reporting and Data System

> Level of suspicion for pulmonary involvement of COVID-19 on chest CT.

**Status:** current · **Organ:** Chest · **Issuing body:** Dutch Radiological Society · **Version:** 2020 · **Year:** 2020

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Very low suspicion | Very low level of suspicion for pulmonary involvement of COVID-19: either a normal CT or CT findings of an unequivocally non-infectious cause. Concomitant findings such as mild or severe emphysema, perifissural nodules, lung tumours or fibrosis are placed here. Equivalent to the RSNA 'negative for pneumonia' category. | — | Very low suspicion of COVID-19 pulmonary involvement. | Section 'CO-RADS 1' under 'CO-RADS, the COVID-19 Reporting and Data System' | ✓ |
| 2 | Low suspicion | Low level of suspicion: lung findings typical of an infectious cause considered not compatible with COVID-19 (e.g. bronchitis, infectious bronchiolitis, bronchopneumonia, lobar pneumonia, pulmonary abscess), with features such as tree-in-bud sign, centrilobular nodular pattern, lobar or segmental consolidation, and cavitation. Overlaps with the RSNA 'atypical appearance' category. | — | Low suspicion of COVID-19 pulmonary involvement. | Section 'CO-RADS 2' | ✓ |
| 3 | Equivocal | Equivocal/indeterminate level of suspicion: features that can also occur in other viral pneumonias or non-infectious causes, e.g. perihilar ground-glass, homogeneous extensive ground-glass (with or without sparing of some secondary lobules), ground-glass with smooth interlobular septal thickening with/without pleural effusion, small non-centrilobular ground-glass opacities not abutting the visceral pleura, and consolidation patterns compatible with organizing pneumonia, in the absence of other typical COVID-19 findings. | — | Equivocal/indeterminate suspicion of COVID-19 pulmonary involvement. | Section 'CO-RADS 3' | ✓ |
| 4 | High suspicion | High level of suspicion: findings typical for COVID-19 but with some overlap with other (viral) pneumonias. Findings resemble CO-RADS 5 but are not in contact with the visceral pleura, are strictly unilateral, are in a predominantly peribronchovascular distribution, or are superimposed on severe diffuse pre-existing lung abnormalities. Corresponds to the higher-likelihood part of the RSNA 'indeterminate appearance' category. | — | High suspicion of COVID-19 pulmonary involvement. | Section 'CO-RADS 4' | ✓ |
| 5 | Very high suspicion | Very high level of suspicion: typical CT findings, namely ground-glass opacities (with or without consolidation) located in lung regions close to the visceral pleural surfaces including the fissures, with a multifocal bilateral distribution; subpleural sparing may be present. At least one of the typical confirmatory features must be present (e.g. multifocal ground-glass with rounded/unsharp demarcation, crazy-paving with intralobular lines, increasing consolidation, reverse halo/organizing-pneumonia-like changes, subpleural curvilinear bands, thickened vessels within abnormalities). Largely identical to the RSNA 'typical appearance' category. | — | Very high suspicion of COVID-19 pulmonary involvement. | Section 'CO-RADS 5' and Table 2 ('Features typical for COVID-19') | ✓ |
| 6 | PCR proven | Proven COVID-19, indicated by a positive RT-PCR test for SARS-CoV-2 specific nucleic acid at the time of examination. Introduced analogously to BI-RADS 6. | — | Proven COVID-19 (RT-PCR positive). | Section 'CO-RADS 6' | ✓ |

### Per-category citations
- **1**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 1' under 'CO-RADS, the COVID-19 Reporting and Data System'
- **2**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 2'
- **3**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 3'
- **4**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 4'
- **5**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 5' and Table 2 ('Features typical for COVID-19')
- **6**: Prokop M, van Everdingen W, van Rees Vellinga T, et al.. CO-RADS: A Categorical CT Assessment Scheme for Patients Suspected of Having COVID-19 (2020) — https://doi.org/10.1148/radiol.2020201473 · Section 'CO-RADS 6'

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2020-04-27 | published | CO-RADS published in Radiology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/co-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/co-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Fleischner — Fleischner Society 2017 pulmonary nodule guidelines

> Management recommendations for incidentally detected pulmonary nodules on CT, organized by nodule type (solid, subsolid) and size, for patients 35 and older without known cancer or immunosuppression.

**Status:** current · **Organ:** Chest · **Issuing body:** Fleischner Society · **Version:** 2017 · **Year:** 2017

## Provenance and currency
- Family: algorithm
- Logic type: matrix
- Modality: CT
- Primary source: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the matching outcome_code for cited management and risk text. Do not apply this incidental-nodule algorithm to screening CT, known primary cancer, or immunosuppression.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| solid-single-<6 | Solid single nodule, under 6 mm | Single solid nodule under 6 mm (under ~100 mm3); recommendation differs by patient risk. | Low risk: no routine follow-up. High risk: optional CT at 12 months. The guideline notes that nodules under 6 mm generally need no routine follow-up, but selected high-risk patients with suspicious morphology and/or upper-lobe location may warrant a 12-month follow-up. | Average malignancy risk is under 1% even in high-risk patients; suspicious morphology and/or upper-lobe location can raise the estimated risk into the 1%-5% range. | Fleischner 2017 Table 1, Section A (Solid Nodules), Single, <6 mm row | ✓ |
| solid-single-6to8 | Solid single nodule, 6 to 8 mm | Single solid noncalcified nodule with mean diameter 6-8 mm (approximately 100-250 mm3); follow-up intensity depends on clinical risk and morphology. | Low risk: CT at 6-12 months, then consider CT at 18-24 months if morphology is suspicious or stability is uncertain. High risk: CT at 6-12 months and again at 18-24 months. | The guideline estimates an average malignancy risk of approximately 0.5%-2.0% for solitary solid nodules in this size band; individual risk varies with morphology and patient factors. | Fleischner 2017 Table 1, Section A (Solid Nodules), Single, 6-8 mm row | ✓ |
| solid-single->8 | Solid single nodule, over 8 mm | Single solid nodule larger than 8 mm (over ~250 mm3); same management for low and high risk. | Consider CT at 3 months, PET/CT, or tissue sampling (applies to both low- and high-risk single nodules). | The guideline cites an average malignancy risk of approximately 3% for an 8-mm solitary nodule, while emphasizing that risk may be substantially higher according to size, morphology, location, and clinical factors. | Fleischner 2017 Table 1, Section A (Solid Nodules), Single, >8 mm row | ✓ |
| solid-multiple-<6 | Solid multiple nodules, under 6 mm | Multiple solid nodules with the largest under 6 mm; recommendation differs by patient risk. Use the most suspicious nodule to guide management. | Low risk: no routine follow-up. High risk: optional CT at 12 months. | Most multiple solid nodules under 6 mm are benign healed granulomas or intrapulmonary lymph nodes; the guideline does not publish a per-row malignancy probability. | Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, <6 mm row | ✓ |
| solid-multiple->=6 | Solid multiple nodules, 6 mm or larger | Multiple solid nodules with at least one in the 6-8 mm or >8 mm band. Use the most suspicious nodule to guide management; intervals may vary with size and risk. | CT at 3-6 months. At 18-24 months, CT is optional for low-risk patients and recommended for high-risk patients. If one nodule is larger or more suspicious, use its corresponding solitary-nodule pathway to guide management. | No per-row malignancy percentage is given. The most suspicious nodule, which may not be the largest, drives risk assessment; multiplicity and the distribution and morphology of all nodules remain clinically relevant. | Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, 6-8 mm and >8 mm columns | ✓ |
| ggn-single-<6 | Ground glass single nodule, under 6 mm | Single pure ground-glass nodule under 6 mm. | No routine follow-up. In selected patients with a nodule close to 6 mm, suspicious morphology, or other risk factors, optional CT at approximately 2 and 4 years may be considered. | The guideline cites data in which up to 10% of these nodules grew and nearly 1% progressed to adenocarcinoma over many years, supporting conservative management for most patients. | Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, <6 mm column | ✓ |
| ggn-single->=6 | Ground glass single nodule, 6 mm or larger | Single pure ground-glass nodule 6 mm or larger. | CT at 6-12 months to confirm persistence, then CT every 2 years out to 5 years. If a solid component or growth develops, consider resection. | Persistent pure ground-glass nodules can represent indolent adenocarcinoma-spectrum lesions; the guideline notes that growth commonly requires 3-4 years to establish and does not provide a single per-row malignancy percentage. | Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, >=6 mm column | ✓ |
| partsolid-single-<6 | Part solid single nodule, under 6 mm | Single apparent part-solid nodule under 6 mm. A discrete solid component cannot be measured reliably at this size, so the guideline treats it like a pure ground-glass nodule of the same size. | No routine follow-up. Optional longer-term CT may be considered in selected patients when the nodule is close to 6 mm or has suspicious morphology or other risk factors. | The guideline does not publish a separate malignancy probability for apparent part-solid nodules under 6 mm because a true solid component is not reliably defined at this size. | MacMahon et al. 2017, Recommendation 4 (solitary part-solid nodules), first paragraph; Table 1 Section B, <6 mm column | ✓ |
| partsolid-single->=6 | Part solid single nodule, 6 mm or larger | Single part-solid nodule 6 mm or larger. The guideline notes part-solid nodules are generally not defined as such below 6 mm, and persistent part-solid nodules with a solid component of 6 mm or more should be regarded as highly suspicious. | CT at 3-6 months to confirm persistence. If unchanged and the solid component stays under 6 mm, annual CT for at least 5 years. If the solid component is 6 mm or larger, grows, exceeds 8 mm, or morphology is particularly suspicious, consider PET/CT, biopsy, or resection. | Part-solid nodules have a high likelihood of malignancy. A persistent solid component under 6 mm more often represents adenocarcinoma in situ or minimally invasive adenocarcinoma; a component 6 mm or larger is highly suspicious for invasive disease. | Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Part solid, >=6 mm column | ✓ |
| subsolid-multiple | Multiple subsolid nodules | Multiple subsolid nodules (ground-glass and/or part-solid). Multiple sub-6 mm pure ground-glass nodules are usually benign. | Under 6 mm: CT at 3-6 months; if stable, consider CT at 2 and 4 years. 6 mm or larger: CT at 3-6 months, with subsequent management based on the most suspicious nodule(s). | Multiple tiny subsolid nodules may be infectious or inflammatory. If persistent, they may represent atypical adenomatous hyperplasia or adenocarcinoma in situ; when at least one lesion is 6 mm or larger, more than one suspicious lesion increases the overall likelihood of cancer. | Fleischner 2017 Table 1, Section B (Subsolid Nodules), Multiple row | ✓ |

### Per-category citations
- **solid-single-<6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section A (Solid Nodules), Single, <6 mm row
- **solid-single-6to8**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section A (Solid Nodules), Single, 6-8 mm row
- **solid-single->8**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section A (Solid Nodules), Single, >8 mm row
- **solid-multiple-<6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, <6 mm row
- **solid-multiple->=6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, 6-8 mm and >8 mm columns
- **ggn-single-<6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, <6 mm column
- **ggn-single->=6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, >=6 mm column
- **partsolid-single-<6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · MacMahon et al. 2017, Recommendation 4 (solitary part-solid nodules), first paragraph; Table 1 Section B, <6 mm column
- **partsolid-single->=6**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Part solid, >=6 mm column
- **subsolid-multiple**: MacMahon H, Naidich DP, Goo JM, et al.. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 (2017) — https://doi.org/10.1148/radiol.2017161659 · Fleischner 2017 Table 1, Section B (Subsolid Nodules), Multiple row

## Cross-references
- _shared boundary_ → [Lung-RADS — Lung CT Screening Reporting and Data System](https://radcommons.laudos.ai/systems/lung-rads-2022.md) — Fleischner governs incidental nodules, Lung-RADS governs screening detected nodules.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2017-07-01 | revised | Fleischner Society 2017 guidelines published, updating the 2005 recommendations. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/fleischner-2017 · API JSON: https://radcommons.laudos.ai/api/v1/systems/fleischner-2017 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lung-RADS — Lung CT Screening Reporting and Data System

> Structured assessment categories and management for low dose CT lung cancer screening.

**Status:** current · **Organ:** Chest · **Issuing body:** American College of Radiology · **Version:** v2022 · **Year:** 2022

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use in screening only. Follow the cited outcome for management; category timing is measured from the exam currently being interpreted.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Incomplete | Incomplete: a prior chest CT is being located for comparison, part or all of the lungs cannot be evaluated, or findings suggest an inflammatory/infectious process. | Obtain comparison with prior chest CT and/or additional lung-cancer-screening CT; for suspected infection/inflammation, 1-3 month LDCT. | Published estimated population prevalence ~1% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 0 row | ✓ |
| 1 | Negative | Negative: no lung nodules, or nodules with definitely benign features (complete/central/popcorn/concentric-ring calcification, or fat-containing). | Continue annual screening with 12-month LDCT. | Published estimated population prevalence 39% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 1 row | ✓ |
| 2 | Benign appearance or behavior | Benign by imaging features or indolent behavior. Includes: juxtapleural nodule under 10 mm with benign morphology; solid nodule under 6 mm at baseline or new under 4 mm; part-solid nodule with total mean diameter under 6 mm at baseline; non-solid (ground-glass) nodule under 30 mm at baseline/new/growing, or >=30 mm if stable/slowly growing; subsegmental airway nodule. | Continue annual screening with 12-month LDCT. | Published estimated population prevalence 45% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 2 row | ✓ |
| 3 | Probably benign | Probably benign. Includes: solid nodule 6 to under 8 mm at baseline (or new 4 to under 6 mm); part-solid nodule with total mean diameter >=6 mm and solid component under 6 mm at baseline (or new under 6 mm total); non-solid (ground-glass) nodule >=30 mm at baseline or new; thick-walled atypical cyst with a growing cystic component. | Short-interval follow-up with 6-month LDCT. If stable or decreased at that exam, reclassify as Lung-RADS 2 and obtain the next screening LDCT 12 months from the current exam. | Published estimated population prevalence 9% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 3 row | ✓ |
| 4A | Suspicious | Suspicious. Includes: solid nodule 8 to under 15 mm at baseline (or growing under 8 mm, or new 6 to under 8 mm); part-solid nodule with total mean diameter >=6 mm and solid component 6 to under 8 mm at baseline (or new/growing solid component under 4 mm); segmental or more proximal airway nodule at baseline; certain atypical pulmonary cysts (thick-walled, or multilocular at baseline, or one becoming multilocular). | 3-month LDCT; PET/CT may be considered when there is a solid nodule or solid component of 8 mm or larger. If stable or decreased at 3 months, reclassify as Lung-RADS 3 and obtain 6-month LDCT from that current exam; if again stable or decreased, step down to category 2 with 12-month LDCT from the latest exam. | Published estimated population prevalence 4% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 4A row | ✓ |
| 4B | Very suspicious | Very suspicious. Includes: solid nodule >=15 mm at baseline (or new/growing >=8 mm); part-solid nodule with solid component >=8 mm at baseline (or new/growing solid component >=4 mm); certain growing/atypical cysts; slow-growing solid or part-solid nodule that demonstrates growth over multiple screening exams; segmental or more proximal airway nodule that is stable or growing. | Diagnostic chest CT with or without contrast; PET/CT may be considered when there is a solid nodule or solid component >=8 mm; tissue sampling and/or referral for further clinical evaluation. Management depends on comorbidities, patient preference, and probability of malignancy. Slowly growing nodules may be PET-negative, so biopsy or surgical evaluation may be more appropriate when feasible. | Published estimated population prevalence 2% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 4B row | ✓ |
| 4X | Very suspicious with additional features | Category 3 or 4 nodules that carry additional features or imaging findings increasing suspicion for lung cancer (e.g., spiculation, lymphadenopathy, frank metastatic disease, a ground-glass nodule that doubles in size within a year). | Referral for further clinical evaluation (managed as a very-suspicious finding). | Published estimated population prevalence under 1% (this is a prevalence figure, not a probability of malignancy). | Lung-RADS v2022 assessment categories table, Category 4X row | ✓ |
| S | Significant non-lung-cancer finding modifier | Optional exam modifier added to a numeric Lung-RADS category 0-4 when there is a clinically significant or potentially clinically significant finding unrelated to lung cancer. Do not keep applying S to a finding that is already known and has been or is being evaluated unless there is an unexpected concerning change. | Manage according to the specific non-lung-cancer finding, using applicable ACR Incidental Findings recommendations or another appropriate clinical pathway; S does not alter the numeric Lung-RADS nodule category. | Not a lung-cancer risk category. S flags a separate significant or potentially significant incidental finding. | Lung-RADS v2022 Note 15 (Exam Modifier) and v2022 Summary of Changes, section II.B (S Modifier) | ✓ |

### Per-category citations
- **0**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 0 row
- **1**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 1 row
- **2**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 2 row
- **3**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 3 row
- **4A**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 4A row
- **4B**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 4B row
- **4X**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 assessment categories table, Category 4X row
- **S**: ACR Lung-RADS Committee. Lung CT Screening Reporting and Data System (Lung-RADS) version 2022 (2022) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/Lung-Rads · Lung-RADS v2022 Note 15 (Exam Modifier) and v2022 Summary of Changes, section II.B (S Modifier)

## Cross-references
- _shared boundary_ → [BI-RADS — Breast Imaging Reporting and Data System, 5th edition](https://radcommons.laudos.ai/systems/bi-rads-2013.md) — Shares the ACR Reporting and Data System framework that BI-RADS established.
- _shared boundary_ → [Fleischner — Fleischner Society 2017 pulmonary nodule guidelines](https://radcommons.laudos.ai/systems/fleischner-2017.md) — Both address pulmonary nodules on CT. Lung-RADS governs screening, Fleischner governs incidental nodules.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2022-11-01 | revised | Lung-RADS v2022 released, updating v1.1 (2019). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lung-rads-2022 · API JSON: https://radcommons.laudos.ai/api/v1/systems/lung-rads-2022 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# RSNA COVID — RSNA chest CT reporting categories for acute COVID-19 pneumonia

> Standardizes the typicality of acute chest CT patterns potentially attributable to COVID-19 pneumonia. It is a communication lexicon, not a viral diagnostic test, severity score, screening indication or post-COVID follow-up framework.

**Status:** current · **Organ:** Chest · **Issuing body:** RSNA / STR / ACR · **Version:** 2020 acute-pneumonia reporting consensus · **Year:** 2020

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Simpson S, Kay FU, Abbara S, et al.. Radiological Society of North America expert consensus statement on reporting chest CT findings related to COVID-19 (2020) — https://doi.org/10.1148/ryct.2020200152
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use this as a morphology communication lexicon for acute chest CT, never as a binary SARS-CoV-2 test or severity score. Preserve timing, laboratory context, mixed processes, complications and the 2025 post-COVID terminology boundary.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| typical | Typical appearance | Typical appearance requires a characteristic acute-pneumonia pattern: peripheral bilateral or multifocal rounded ground-glass opacity, with or without consolidation or visible intralobular lines/crazy paving, and/or an organizing-pneumonia pattern such as reverse halo. Preserve a mixed atypical component separately rather than hiding it behind the category. | Use the standardized reporting phrase, describe distribution and extent, and correlate with symptoms, exposure, local viral testing and infection-control policy. CT is not a screening or stand-alone first-line diagnostic test, and this label alone must not trigger or withhold treatment. | This is a morphology/typicality category, not a positive virologic diagnosis, probability estimate or severity grade. Its positive predictive value changes with prevalence, vaccination and circulating variants, and similar organizing-pneumonia patterns occur with other infections, drug toxicity and inflammatory disease. | Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Typical appearance' and pp. 3-5 distribution/morphology discussion; Polyakov et al. 2023, DOI 10.1148/radiol.220680, abstract/results for vaccination-, variant- and prevalence-dependent performance. | ✓ |
| indeterminate | Indeterminate appearance | Indeterminate appearance applies when typical features are absent but ground-glass opacity with or without consolidation remains compatible yet nonspecific: multifocal, diffuse, perihilar or unilateral disease without a rounded peripheral pattern, or only a few small nonrounded and nonperipheral ground-glass opacities. | State the nonspecific imaging pattern and relevant alternatives, then integrate timing, clinical findings and viral testing. Do not promote the label to probable COVID-19, and do not derive isolation, therapy, admission or follow-up solely from this category. | The imaging overlap is broad, including edema, hemorrhage, other infection, drug reaction and inflammatory lung disease. Both false-positive and false-negative interpretation are possible, especially with limited, early, treated or technically degraded examinations. | Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Indeterminate appearance' and accompanying discussion of nonrounded, nonperipheral, unilateral, perihilar and diffuse ground-glass patterns. | ✓ |
| atypical | Atypical appearance | Atypical appearance requires absence of typical and indeterminate patterns plus features uncommon for the original acute COVID-19 phenotype, such as isolated lobar or segmental consolidation without ground-glass opacity, discrete centrilobular/tree-in-bud nodules, cavitation, or smooth septal thickening with pleural effusion. | Describe the dominant alternative pattern and surface urgent or treatable differentials such as bacterial infection, aspiration, edema or cavitating infection. Continue clinical and laboratory assessment when COVID-19 remains plausible; an atypical CT label does not exclude infection. | Calling the pattern atypical can create false reassurance because COVID-19 may coexist with a second process or present outside the consensus phenotype. Mixed findings must retain both components, and CT morphology alone cannot assign a competing diagnosis. | Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Atypical appearance' and pp. 4-5 examples of lobar consolidation, tree-in-bud nodules, cavitation and smooth septal thickening with effusion. | ✓ |
| negative | Negative for pneumonia | Negative for pneumonia means no parenchymal abnormality attributable to pneumonia on the examined CT: no relevant ground-glass opacity or consolidation. Incidental or chronic abnormalities may still be present and should be reported separately. | Use the negative-for-pneumonia phrase only for the CT appearance and continue symptom-, exposure- and test-directed clinical evaluation when infection is suspected. A normal CT must not cancel viral testing, infection precautions or clinical reassessment. | A negative CT does not exclude early, mild or otherwise occult COVID-19 and is not equivalent to a negative viral test. Technical limitation or incomplete lung coverage should produce a limited/unclassifiable result rather than false reassurance. | Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Negative for pneumonia' and discussion that CT may be normal early in infection and is not a screening test. | ✓ |

### Per-category citations
- **typical**: Simpson S, Kay FU, Abbara S, et al.. Radiological Society of North America expert consensus statement on reporting chest CT findings related to COVID-19 (2020) — https://doi.org/10.1148/ryct.2020200152 · Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Typical appearance' and pp. 3-5 distribution/morphology discussion; Polyakov et al. 2023, DOI 10.1148/radiol.220680, abstract/results for vaccination-, variant- and prevalence-dependent performance.
- **indeterminate**: Simpson S, Kay FU, Abbara S, et al.. Radiological Society of North America expert consensus statement on reporting chest CT findings related to COVID-19 (2020) — https://doi.org/10.1148/ryct.2020200152 · Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Indeterminate appearance' and accompanying discussion of nonrounded, nonperipheral, unilateral, perihilar and diffuse ground-glass patterns.
- **atypical**: Simpson S, Kay FU, Abbara S, et al.. Radiological Society of North America expert consensus statement on reporting chest CT findings related to COVID-19 (2020) — https://doi.org/10.1148/ryct.2020200152 · Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Atypical appearance' and pp. 4-5 examples of lobar consolidation, tree-in-bud nodules, cavitation and smooth septal thickening with effusion.
- **negative**: Simpson S, Kay FU, Abbara S, et al.. Radiological Society of North America expert consensus statement on reporting chest CT findings related to COVID-19 (2020) — https://doi.org/10.1148/ryct.2020200152 · Simpson et al. 2020, DOI 10.1148/ryct.2020200152, Table 1 'Negative for pneumonia' and discussion that CT may be normal early in infection and is not a screening test.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2020-03-25 | published | RSNA, STR and ACR published the four-category acute chest CT reporting consensus for findings potentially attributable to COVID-19 pneumonia. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/rsna-covid · API JSON: https://radcommons.laudos.ai/api/v1/systems/rsna-covid · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# UIP HRCT — ATS/ERS/JRS/ALAT HRCT pattern classification for usual interstitial pneumonia

> Classifies one technically adequate HRCT as UIP, probable UIP, indeterminate for UIP, or suggestive of an alternative diagnosis. The pattern is morphology, not etiology: UIP can occur outside idiopathic pulmonary fibrosis, and no category alone diagnoses IPF, predicts an individual course, orders biopsy, or starts antifibrotic therapy.

**Status:** current · **Organ:** Chest · **Issuing body:** ATS / ERS / JRS / ALAT · **Version:** 2018 four-pattern framework; 2022 diagnostic update; 2025 multidisciplinary terminology context · **Year:** 2018

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Raghu G, Remy-Jardin M, Myers JL, et al.. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline (2018) — https://www.thoracic.org/statements/resources/interstitial-lung-disease/diagnosis-IPF-full-length.pdf
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify the CT pattern, then reason about etiology and diagnosis. Pattern, diagnosis, prognosis, sampling and treatment are separate agent outputs.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| uip | UIP pattern | UIP HRCT pattern: subpleural and basal-predominant fibrosis, often heterogeneous, with honeycombing. Peripheral traction bronchiectasis or bronchiolectasis may coexist; mild ground-glass opacity may coexist but must not be the dominant abnormality. A dominant alternative distribution or feature prevents an uncomplicated UIP assignment. | After medication, exposure and connective-tissue-disease causes have been assessed, an HRCT UIP pattern in an appropriate IPF diagnostic setting generally avoids lung biopsy solely to prove UIP and should be integrated in multidisciplinary discussion. It does not itself start antifibrotic therapy, select transplant evaluation or exclude treatment for another cause. | UIP morphology strongly supports histopathologic UIP in the intended population, but it is not synonymous with idiopathic pulmonary fibrosis and is not a calibrated individual prognosis. Secondary UIP-pattern disease and acute superimposed processes remain possible. | Raghu et al. 2018 official guideline, DOI 10.1164/rccm.201807-1255ST, Table 4 UIP column and diagnostic recommendations; Raghu et al. 2022, PMC9851481, UIP can occur in HP, CTD or exposure-related ILD and updated diagnostic algorithm; Ryerson et al. 2025, DOI 10.1183/13993003.00158-2025, multidisciplinary pattern context. | ✓ |
| probable-uip | Probable UIP pattern | Probable UIP HRCT pattern: subpleural and basal-predominant, often heterogeneous reticulation with peripheral traction bronchiectasis or bronchiolectasis, no honeycombing, and no dominant feature suggesting an alternative diagnosis. Mild ground-glass opacity may be present but is not predominant. | The 2022 update permits a confident IPF diagnosis without histologic sampling in an appropriate clinical setting after multidisciplinary discussion. This is not a universal no-biopsy instruction: exposure and CTD assessment, diagnostic confidence, patient procedural risk and whether tissue would change care determine further testing. | Many patients in the intended older, clinically suspected IPF population have histopathologic UIP, but predictive value changes with age and competing etiologies. Probable UIP neither proves IPF nor means a more favorable or less advanced disease than UIP. | Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 probable-UIP column and pp e49-e50; Raghu et al. 2022, DOI 10.1164/rccm.202202-0399ST, PMC9851481, probable-UIP diagnostic pathway and no-biopsy-in-appropriate-context update. | ✓ |
| indeterminate | Indeterminate for UIP | Indeterminate for UIP: fibrosis is present but the examination meets neither UIP nor probable-UIP criteria and has no feature set that specifically suggests an alternative diagnosis. It includes subtle subpleural reticulation with or without mild ground-glass opacity or distortion sometimes described as an early UIP pattern, once dependent atelectasis has been excluded when necessary. | Clarify technique and dependent opacity, complete the etiologic work-up and use multidisciplinary discussion. BAL, cryobiopsy, surgical biopsy or surveillance may be considered only when case-specific diagnostic value exceeds risk; indeterminate does not automatically mandate tissue sampling or empiric IPF therapy. | The category expresses unresolved morphology, not intermediate clinical severity or a fixed probability of IPF. Histopathologic UIP, another fibrotic ILD or an early/limited process can underlie it, and one CT cannot establish progression or prognosis. | Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 and indeterminate-for-UIP section including prone confirmation of subtle dependent subpleural opacity; Raghu et al. 2022, PMC9851481, diagnostic combinations and TBLC boundary. | ✓ |
| alternative | Alternative diagnosis | Suggestive of an alternative diagnosis: a dominant feature or distribution such as marked mosaic attenuation or extensive air trapping, predominant ground-glass opacity, cysts, profuse micronodules or centrilobular nodules, consolidation, peribronchovascular/perilymphatic or upper/mid-lung predominance, subpleural sparing, or supportive pleural/extrapulmonary clues. | Name the leading alternative and pursue disease-specific clinical, exposure, serologic, bronchoalveolar or tissue evaluation through multidisciplinary review. The category neither proves one alternative disease nor automatically excludes IPF, and it cannot independently select immunosuppression, antifibrotic therapy or biopsy. | These findings reduce confidence that the CT represents uncomplicated IPF-pattern UIP and can point toward fibrotic hypersensitivity pneumonitis, CTD-ILD, fibrotic NSIP, sarcoidosis, asbestos-related disease or another cause. The category is diagnostic direction, not a severity or survival tier. | Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 alternative-diagnosis column and examples; Raghu et al. 2022, PMC9851481, radiographic UIP and etiologic boundary; Ryerson et al. 2025, DOI 10.1183/13993003.00158-2025. | ✓ |

### Per-category citations
- **uip**: Raghu G, Remy-Jardin M, Myers JL, et al.. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline (2018) — https://www.thoracic.org/statements/resources/interstitial-lung-disease/diagnosis-IPF-full-length.pdf · Raghu et al. 2018 official guideline, DOI 10.1164/rccm.201807-1255ST, Table 4 UIP column and diagnostic recommendations; Raghu et al. 2022, PMC9851481, UIP can occur in HP, CTD or exposure-related ILD and updated diagnostic algorithm; Ryerson et al. 2025, DOI 10.1183/13993003.00158-2025, multidisciplinary pattern context.
- **probable-uip**: Raghu G, Remy-Jardin M, Myers JL, et al.. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline (2018) — https://www.thoracic.org/statements/resources/interstitial-lung-disease/diagnosis-IPF-full-length.pdf · Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 probable-UIP column and pp e49-e50; Raghu et al. 2022, DOI 10.1164/rccm.202202-0399ST, PMC9851481, probable-UIP diagnostic pathway and no-biopsy-in-appropriate-context update.
- **indeterminate**: Raghu G, Remy-Jardin M, Myers JL, et al.. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline (2018) — https://www.thoracic.org/statements/resources/interstitial-lung-disease/diagnosis-IPF-full-length.pdf · Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 and indeterminate-for-UIP section including prone confirmation of subtle dependent subpleural opacity; Raghu et al. 2022, PMC9851481, diagnostic combinations and TBLC boundary.
- **alternative**: Raghu G, Remy-Jardin M, Myers JL, et al.. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline (2018) — https://www.thoracic.org/statements/resources/interstitial-lung-disease/diagnosis-IPF-full-length.pdf · Raghu et al. 2018, DOI 10.1164/rccm.201807-1255ST, Table 4 alternative-diagnosis column and examples; Raghu et al. 2022, PMC9851481, radiographic UIP and etiologic boundary; Ryerson et al. 2025, DOI 10.1183/13993003.00158-2025.

## Cross-references
- _shared boundary_ → [RSNA COVID — RSNA chest CT reporting categories for acute COVID-19 pneumonia](https://radcommons.laudos.ai/systems/rsna-covid.md) — UIP categories describe a chronic fibrotic background; RSNA COVID categories describe acute pneumonia typicality. New ground-glass opacity can be an acute overlay, and neither system may be translated into the other.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-12-04 | revised | The current ERS/ATS interstitial-pneumonia statement expanded multidisciplinary pattern terminology beyond idiopathic disease and emphasized diagnostic confidence without converting UIP morphology into a single etiology. | confirmed |
| 2022-05-01 | revised | The ATS/ERS/JRS/ALAT update retained the four HRCT patterns, allowed probable UIP to support an IPF diagnosis without biopsy in the appropriate multidisciplinary clinical setting, and conditionally accepted TBLC as an SLB alternative in experienced centers. | confirmed |
| 2018-09-01 | published | 2018 ATS/ERS/JRS/ALAT clinical practice guideline for the diagnosis of idiopathic pulmonary fibrosis published, refining the HRCT pattern categories. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/uip-ct-2018 · API JSON: https://radcommons.laudos.ai/api/v1/systems/uip-ct-2018 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# C-RADS — CT Colonography Reporting and Data System version 2023

> Current CT-colonography reporting framework with separate colorectal C and extracolonic E axes. The active colorectal map is C0, C1, C2a, C2b, C3 and C4: C0 is nonassessable rather than low risk; C2a and C2b encode different findings and follow-up logic; and C4 is imaging suspicion rather than histology or pathologic stage.

**Status:** current · **Organ:** Colon · **Issuing body:** American College of Radiology · **Version:** v2023 update (published and corrected 2024) · **Year:** 2024

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply current C-RADS v2023 to one CTC examination, retain lesion-level facts, separate C from E, and never collapse technical inadequacy, imaging suspicion and pathology into one label.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| C0 | Inadequate examination or comparison pending | Assign C0 when a confident colorectal interpretation is not possible because a technical limitation prevents exclusion of a polyp 10 mm or larger, such as complete segmental collapse, insufficient insufflation or inadequate cleansing, or when a prior study required for comparison is unavailable. A mass-like but interpretable likely benign diverticular segment belongs in C2b rather than C0. | Repeat or complete the CT colonography when visualization is inadequate, consider an alternative colorectal screening test, or amend the report after the required prior examination becomes available. State the exact nonassessable segment and limitation rather than treating C0 as a negative examination. | C0 does not estimate colorectal-neoplasia risk: the relevant colon is not adequately assessable, so an important lesion has not been excluded. It must never be translated into low risk, benignity or a routine negative-screen interval. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C0 section; lines describing the >=10-mm exclusion limit, missing priors, C2b distinction and repeat/alternative/addendum options. | ✓ |
| C1 | Normal colon or benign lesion | Assign C1 only when the entire colon is adequately cleansed and distended and no polyp measures 6 mm or larger. The category may include a normal colon, diminutive nonreportable polyps 5 mm or smaller, diverticula, confidently benign myochosis or muscular hypertrophy, lipoma, and confidently characterized residual fecal material. | Continue routine CT-colonography screening at a 5- to 10-year interval. Any decision to shorten the interval should be justified by the complete clinical and colonic context, such as extensive diverticulosis or inflammatory change, rather than by the C1 label alone. | C1 denotes no colorectal abnormality that increases carcinoma risk in the setting of regular screening, but it is not zero lifetime risk and does not negate interval symptoms or future screening. The classification also does not supply an individualized cancer probability. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C1 section; adequate whole-colon requirement, <6-mm boundary, benign examples and 5-10-year screening recommendation. | ✓ |
| C2a | One or two 6-9 mm polyps | Assign current C2a, formerly C2, when the examination contains one or two colonic polyps and each measures 6-9 mm inclusive. Record each lesion's largest diameter, segment, morphology, measurement method and confidence; unequivocal interval growth at surveillance changes the examination to C3. | Recommend repeat CT colonography in 3 years to assess growth versus optional colonoscopy with polypectomy, using patient age, comorbidities, preferences, reader confidence and local practice to choose the pathway. Low confidence can justify a shorter interval; demonstrated growth is managed as C3. | In cited surveillance series, 22%-35% of 6-9-mm polyps progressed within 3 years and about 10%-14% resolved. These are cohort observations, not this lesion's probability; CT colonography cannot determine dysplasia or histology from the C2a label. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Subcategory C2a section; one-or-two count, 6-9-mm range, 22%-35% growth, 10%-14% resolution and 3-year-versus-colonoscopy guidance. | ✓ |
| C2b | Likely benign mass-like diverticular or muscular lesion | Assign C2b to a soft-tissue mass or mass-like colonic area that is likely benign, including moderate or severe diverticular myochosis, muscular hypertrophy or a stricture in which malignancy is not entirely excluded. Preserved haustra, absent 3D mucosal irregularity, diverticulosis and lack of overhanging shoulders support this category. | When benignity is highly likely, suggest routine CT-colonography follow-up at 5 years. When confidence is lower, use a shortened interval of 3 years or less according to context. If concern for malignancy is high, classify the lesion as C4 and recommend flexible sigmoidoscopy or colonoscopy rather than retaining C2b. | C2b expresses likely benign morphology with residual diagnostic uncertainty; it is not a numerical malignancy-risk band or histologic diagnosis. Risk depends on the complete morphology, positional change, prior stability, symptoms and clinical context, so uncertainty and confidence must be explicit. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Subcategory C2b section including Figures 5-6; morphologic features, prior comparison, 5-year/<=3-year follow-up and C4 escalation. | ✓ |
| C3 | Polyp, multiplicity, growth or subepithelial lesion requiring colonoscopy | Assign C3 for one or more polyps measuring at least 10 mm, three or more polyps each measuring 6-9 mm, unequivocal interval growth of a prior C2a polyp, or a suspected subepithelial lesion measuring at least 10 mm. Preserve which branch triggered the overall category. | Recommend colonoscopic polypectomy. If colonoscopic removal cannot be performed because of distal narrowing or severe tortuosity, short-interval CT colonography within 1 year or surgical referral may be appropriate according to patient age, comorbidities, anatomy and lesion features. | Polyps at least 1 cm have a reported 10%-25% likelihood of high-grade dysplasia or carcinoma, with risk increasing with size. This source range is population context rather than an individual prediction, and C3 does not prove advanced histology or cancer. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C3 section; size, multiplicity, growth, subepithelial-lesion branches, 10%-25% range and colonoscopy/alternative guidance. | ✓ |
| C4 | Polypoid mass at least 30 mm or malignant-appearing mass | Assign C4 for a polypoid soft-tissue mass measuring at least 30 mm or for a malignant-appearing colonic mass. Describe length, morphology, location, obstruction or narrowing, synchronous lesions, nodes and possible distant disease when technically assessable rather than replacing those findings with the code. | Recommend surgical and/or oncologic consultation, with or without preoperative colonoscopic biopsy. Intravenous-contrast CT colonography may contribute to staging, but the C4 label alone does not select an operation, establish resectability or replace tissue diagnosis and formal staging. | C4 represents high imaging suspicion for malignancy, not histologic confirmation, TNM stage, operability or an individualized prognosis. A benign final diagnosis remains possible, so the report must preserve uncertainty and the evidence supporting the malignant appearance. | Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C4 section; >=30-mm polypoid-mass or malignant-appearance definition and surgical/oncologic consultation with optional biopsy. | ✓ |

### Per-category citations
- **C0**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C0 section; lines describing the >=10-mm exclusion limit, missing priors, C2b distinction and repeat/alternative/addendum options.
- **C1**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C1 section; adequate whole-colon requirement, <6-mm boundary, benign examples and 5-10-year screening recommendation.
- **C2a**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Subcategory C2a section; one-or-two count, 6-9-mm range, 22%-35% growth, 10%-14% resolution and 3-year-versus-colonoscopy guidance.
- **C2b**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Subcategory C2b section including Figures 5-6; morphologic features, prior comparison, 5-year/<=3-year follow-up and C4 escalation.
- **C3**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C3 section; size, multiplicity, growth, subepithelial-lesion branches, 10%-25% range and colonoscopy/alternative guidance.
- **C4**: Yee J, Dachman A, Kim DH, et al.. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update (2024) — https://pubs.rsna.org/doi/10.1148/radiol.232007 · Yee et al. Radiology 2024, DOI 10.1148/radiol.232007, Table 2 and Category C4 section; >=30-mm polypoid-mass or malignant-appearance definition and surgical/oncologic consultation with optional biopsy.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2024-01-30 | revised | C-RADS v2023 became the current corrected release: prior C2 was renamed C2a, new C2b was added for likely benign mass-like diverticular strictures, and the extracolonic E1 and E2 categories were combined as E1/E2. | confirmed |
| 2005-07-01 | published | C-RADS consensus proposal published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/c-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/c-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Modified Hinchey — Kaiser CT-modified Hinchey classification of acute diverticulitis

> Six-category CT and clinical severity map from stage 0 through IV: mild disease, confined inflammation, local or distant abscess, and generalized purulent or fecal peritonitis. Name this Kaiser modification and keep it separate from original operative Hinchey and WSES CT stages; the code alone does not prescribe treatment.

**Status:** current · **Organ:** Colon · **Issuing body:** Kaiser et al. / colorectal-surgery practice · **Version:** Kaiser CT modification (2005); current-care context reviewed through 2026 · **Year:** 2005

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the complete six-stage Kaiser CT modification, preserve CT-versus-operative truth and clinical physiology, and never import WSES numbering or a management-size threshold into the stage silently.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Stage 0, clinically mild diverticulitis | Kaiser modified Hinchey stage 0 is a clinically mild acute diverticulitis episode with colonic diverticula and with or without colonic wall thickening, without definite pericolic inflammatory reaction, abscess or generalized peritonitis. It is not asymptomatic diverticulosis and must be tied to the acute clinical episode. | For a carefully selected low-risk, immunocompetent patient with mild uncomplicated disease, no systemic inflammatory response and reliable follow-up, current ACG guidance suggests against routine antibiotics. High-risk features, immunocompromise, frailty, vomiting, severe or refractory symptoms, concerning laboratory/imaging findings or unreliable follow-up support antibiotics, closer observation or admission according to the complete clinical assessment. | This is the least anatomically advanced modified category, but it has no universal recurrence or complication probability. In the historical Kaiser cohort, broadly defined mild cases had 13% recurrence; that center-era figure is not a stage-0 individual prediction and does not override immune status, physiology or follow-up reliability. | Tiralongo et al. 2023, PMC10742435, modified Hinchey table, stage 0; Kaiser et al. 2005, PMID 15784040, recurrence results for mild cases; Peery et al. 2026 ACG guideline recommendations for low-risk uncomplicated diverticulitis. | ✓ |
| Ia | Stage Ia, confined pericolic inflammation or phlegmon | Confined pericolic inflammation or phlegmon is present: CT shows colonic wall thickening with inflammatory reaction in the adjacent pericolic fat, without a drainable pericolic/mesocolic abscess, distant abscess or generalized peritonitis. Pericolic gas must be described separately because other named systems encode it differently. | Stable, selected uncomplicated cases may receive supportive outpatient care without routine antibiotics under current ACG criteria. If there is pericolic extraluminal gas, systemic inflammation, immune compromise, frailty or other high-risk features, use antibiotics and close reassessment; WSES specifically suggests a nonoperative antibiotic trial for pericolic gas. No drain is placed without a drainable collection. | Ia generally has lower failure risk than abscess or generalized-peritonitis categories, but the label alone has no calibrated probability. Clinical deterioration, high inflammatory burden, immune compromise and pericolic gas can change risk despite the absence of an abscess; preserve those variables instead of reporting a fixed percentage. | Tiralongo et al. 2023, PMC10742435, modified Hinchey stage Ia table; Sartelli et al. 2020, PMC7206757, pericolic-gas recommendation and WSES scheme; Peery et al. 2026 ACG guideline for selective antibiotic use and high-risk features. | ✓ |
| Ib | Stage Ib, confined pericolic or mesocolic abscess | A confined pericolic or mesocolic abscess lies near the primary inflammatory process, with the stage-Ia wall and pericolic inflammatory changes. The historical Kaiser table describes the local collection as less than 5 cm; record three dimensions and location because current drainage thresholds and other classification schemes use different cutoffs. | Use antibiotics and assess whether image-guided drainage is feasible and necessary. WSES supports an antibiotics-alone trial for selected abscesses under about 4-5 cm and drainage plus antibiotics for larger collections; ASCRS usually recommends drainage for stable patients with an abscess over 3 cm. These are different guideline thresholds, not a reason to silently change the Hinchey stage. Escalate for sepsis, deterioration or failed source control. | An abscess increases nonoperative failure and recurrence risk compared with uncomplicated disease. WSES cites about 20% pooled failure and 0.6% mortality for selected limited-size abscesses treated systemically, while the Kaiser cohort found 22.2% of all abscess patients required urgent resection. Neither figure is an Ib-specific bedside probability. | Tiralongo et al. 2023, PMC10742435, stage Ib row and historical less-than 5 cm descriptor; Sartelli et al. 2020, PMC7206757, small/large abscess recommendations and pooled outcomes; Hall et al. 2020 ASCRS guideline, stable abscess over 3 cm drainage recommendation; Kaiser et al. 2005 abscess results. | ✓ |
| II | Stage II, pelvic or other distant abscess | A contained abscess is distant from the primary diverticular inflammatory process, typically pelvic or interloop and potentially intra-abdominal or retroperitoneal. It remains a localized collection rather than generalized purulent or fecal peritonitis. Location is central; do not create stage II solely because a nearby abscess crossed a treatment-size threshold. | Give antibiotics and plan image-guided drainage when feasible based on collection size, access, physiology and expertise; use close monitoring when drainage is unavailable or unsafe. Surgical reassessment is required for worsening sepsis, persistent collection or failed nonoperative care. After recovery, discuss elective resection individually rather than automatically scheduling colectomy from stage II alone. | Distant abscess denotes more extensive complicated disease. In the historical Kaiser cohort, conservatively treated pelvic abscesses had 41.2% recurrence versus 13% in mild cases, but this retrospective center result is not a current individual forecast. Abscess accessibility, immune status, sepsis and response to therapy materially alter risk. | Tiralongo et al. 2023, PMC10742435, stage II row; Kaiser et al. 2005, PMID 15784040, pelvic-abscess recurrence result; Sartelli et al. 2020 and Hall et al. 2020 for drainage/source-control context; Peery et al. 2021 AGA and 2026 ACG guidance for individualized elective management. | ✓ |
| III | Stage III, generalized purulent peritonitis | Generalized purulent peritonitis is present without gross fecal contamination or an open communication between bowel lumen and peritoneal cavity. CT may show free air, local or generalized free fluid and peritoneal thickening, but imaging alone may not reliably establish purulent contamination; clinical and operative findings must be retained. | Initiate urgent resuscitation, broad antimicrobial therapy and operative source control. In current WSES guidance, primary resection with anastomosis with or without diversion is an option for selected stable patients, while Hartmann resection is favored for critical illness or substantial comorbidity. Laparoscopic lavage is reserved for selected cases and is not first-line treatment. | Generalized peritonitis carries high morbidity and mortality, but modified Hinchey III has no universal per-stage probability applicable across physiologic states and operative strategies. Shock, organ dysfunction, contamination burden, age, comorbidity and time to source control are dominant; do not infer futility or a fixed outcome from the Roman stage. | Hinchey et al. 1978, PMID 735943, purulent-peritonitis description; Tiralongo et al. 2023, PMC10742435, stage III CT row; Sartelli et al. 2020, PMC7206757, diffuse peritonitis, lavage and resection recommendations. | ✓ |
| IV | Stage IV, generalized fecal peritonitis | Generalized fecal peritonitis is present from free perforation with open communication to the bowel lumen and gross fecal contamination. Free air alone is insufficient. When contamination type is not known before source control, report suspected stage III-versus-IV rather than manufacturing stage IV from CT gas volume. | Provide immediate resuscitation, broad antimicrobial therapy and emergency operative source control. Procedure choice is individualized: current WSES guidance favors Hartmann resection in critically ill patients or those with major comorbidity, while primary resection and anastomosis with or without diversion may be considered in stable selected patients. The stage does not mandate one operation for every patient. | This is the most severe contamination category and historically carries very high risk, yet no transportable stage-IV mortality percentage is built into the system. Physiology, organ failure, contamination burden, comorbidity, operative timing and available expertise determine individual risk; stage IV alone is neither a prognosis of certainty nor a treatment-limitation signal. | Hinchey et al. 1978, PMID 735943, fecal-peritonitis and individualized operative discussion; Tiralongo et al. 2023, PMC10742435, stage IV CT row; Sartelli et al. 2020, PMC7206757, operative recommendations for diffuse peritonitis. | ✓ |

### Per-category citations
- **0**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Tiralongo et al. 2023, PMC10742435, modified Hinchey table, stage 0; Kaiser et al. 2005, PMID 15784040, recurrence results for mild cases; Peery et al. 2026 ACG guideline recommendations for low-risk uncomplicated diverticulitis.
- **Ia**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Tiralongo et al. 2023, PMC10742435, modified Hinchey stage Ia table; Sartelli et al. 2020, PMC7206757, pericolic-gas recommendation and WSES scheme; Peery et al. 2026 ACG guideline for selective antibiotic use and high-risk features.
- **Ib**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Tiralongo et al. 2023, PMC10742435, stage Ib row and historical less-than 5 cm descriptor; Sartelli et al. 2020, PMC7206757, small/large abscess recommendations and pooled outcomes; Hall et al. 2020 ASCRS guideline, stable abscess over 3 cm drainage recommendation; Kaiser et al. 2005 abscess results.
- **II**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Tiralongo et al. 2023, PMC10742435, stage II row; Kaiser et al. 2005, PMID 15784040, pelvic-abscess recurrence result; Sartelli et al. 2020 and Hall et al. 2020 for drainage/source-control context; Peery et al. 2021 AGA and 2026 ACG guidance for individualized elective management.
- **III**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Hinchey et al. 1978, PMID 735943, purulent-peritonitis description; Tiralongo et al. 2023, PMC10742435, stage III CT row; Sartelli et al. 2020, PMC7206757, diffuse peritonitis, lavage and resection recommendations.
- **IV**: Kaiser AM, Jiang JK, Lake JP, et al.. The management of complicated diverticulitis and the role of computed tomography (2005) — https://pubmed.ncbi.nlm.nih.gov/15784040/ · Hinchey et al. 1978, PMID 735943, fecal-peritonitis and individualized operative discussion; Tiralongo et al. 2023, PMC10742435, stage IV CT row; Sartelli et al. 2020, PMC7206757, operative recommendations for diffuse peritonitis.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2005-04-01 | revised | Kaiser and colleagues applied the six-category CT modification with stage 0 and separate Ia/Ib categories in a 511-patient cohort. | confirmed |
| 1978-01-01 | published | Hinchey, Schaal and Richards published the original four-stage operative classification for perforated diverticular disease. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/hinchey · API JSON: https://radcommons.laudos.ai/api/v1/systems/hinchey · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# St James — St James University Hospital classification of perianal fistula

> Grades perianal fistulas on MRI by anatomy and complications.

**Status:** current · **Organ:** Colon · **Issuing body:** Radiology consensus · **Version:** 2000 · **Year:** 2000

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | Simple linear intersphincteric fistula (single tract penetrating the internal sphincter to run between internal and external sphincters and exit the perineum, with no secondary extension or abscess). | Counts as a 'simple'/low fistula: generally amenable to laying-open (fistulotomy/fistulectomy) with low risk of incontinence, since no external-sphincter muscle is divided. | Favorable: grades 1-2 were associated with a satisfactory outcome, versus grades 3-5 (unsatisfactory, e.g. need for further surgery; P<0.001) in the cited series. | Criteria/management/outcome: PMC4394844 ('MRI of Perianal Fistulas'), section 'Classification of Perianal Fistulae' (Grade 1 = 'a simple intersphincteric fistula' penetrating between the sphincters) and the outcome statement 'grades 1 and 2 were associated with satisfactory outcome whereas grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'; simple/low-fistula fistulotomy principle from the same article. | ✓ |
| 2 | Grade 2 | Intersphincteric fistula with an intersphincteric secondary tract or abscess. | Still intersphincteric (no trans-sphincteric muscle involvement) but with a secondary tract/abscess that must be drained/laid open in addition to treating the primary tract; broadly grouped with the lower-risk fistulas for sphincter-sparing intent. | Favorable: grades 1-2 were associated with a satisfactory outcome (vs unsatisfactory for grades 3-5; P<0.001) in the cited series. | Criteria: PMC4394844, 'Classification of Perianal Fistulae', Grade 2 = 'an intersphincteric fistula with a secondary tract or abscess'. Outcome/risk: same article, 'grades 1 and 2 were associated with satisfactory outcome whereas grades 3-5 ... unsatisfactory ... (P<0.001)'. | ✓ |
| 3 | Grade 3 | Simple (uncomplicated) transsphincteric fistula (tract crosses both the internal and external sphincters into the ischioanal fossa without secondary extension or abscess). | Trans-sphincteric tracts cross the external sphincter, so simple laying-open risks incontinence (>50% with the lay-open technique for complex disease); sphincter-preserving options (e.g. seton, advancement flap) are favored, the more so with the higher grades. | Less favorable: grades 3-5 were associated with an unsatisfactory outcome (e.g. need for further surgery), in contrast to satisfactory outcomes for grades 1-2 (P<0.001) in the cited series. | Criteria: PMC4394844, 'Classification of Perianal Fistulae', Grade 3 = 'simple transphincteric fistulae'. Management/outcome: same article — incontinence '>50%' with laying-open of complex fistulas, and 'grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'. | ✓ |
| 4 | Grade 4 | Transsphincteric fistula with an associated secondary tract or abscess (a more complicated transsphincteric process), typically extending into the ischioanal/ischiorectal fossa. | Complex fistula: laying-open is avoided (incontinence in >50% of cases); managed with sphincter-preserving and/or staged techniques (non-cutting seton, mucosal advancement flap) plus drainage of the secondary tract/abscess. | Unfavorable: grade 4 falls in the grades 3-5 band associated with an unsatisfactory outcome / need for further surgery (vs satisfactory for grades 1-2; P<0.001) in the cited series. | Criteria: PMC4394844, Grade 4 = 'a more complicated transphincteric process with a secondary tract or abscess'; ischioanal/ischiorectal-fossa site corroborated by WebSearch summaries of St James / Morris 2000 on pmc.ncbi.nlm.nih.gov. Management/outcome: same article — complex fistulas need sphincter-preserving/staged surgery (lay-open incontinence '>50%') and 'grades 3-5 ... unsatisfactory outcome ... (P<0.001)'. | ✓ |
| 5 | Grade 5 | Supralevator and/or translevator disease (a complicated fistula/abscess with a supralevator or translevator component, extending above the level of the levator ani). | Most complex group: requires sphincter-preserving and often staged/specialist surgery (seton, advancement flap, treatment of the supra/translevator component) with imaging-guided planning; simple laying-open is contraindicated given the high incontinence risk. | Most unfavorable: grade 5 lies in the grades 3-5 band associated with an unsatisfactory outcome / need for further surgery (vs satisfactory for grades 1-2; P<0.001) in the cited series. | Criteria: PMC4394844, Grade 5 = 'a complicated abscess with a supra or translevator component'. Management/outcome: same article — complex/high disease needs sphincter-preserving/staged surgery (lay-open incontinence '>50%') and 'grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'. | ✓ |

### Per-category citations
- **1**: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/ · Criteria/management/outcome: PMC4394844 ('MRI of Perianal Fistulas'), section 'Classification of Perianal Fistulae' (Grade 1 = 'a simple intersphincteric fistula' penetrating between the sphincters) and the outcome statement 'grades 1 and 2 were associated with satisfactory outcome whereas grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'; simple/low-fistula fistulotomy principle from the same article.
- **2**: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/ · Criteria: PMC4394844, 'Classification of Perianal Fistulae', Grade 2 = 'an intersphincteric fistula with a secondary tract or abscess'. Outcome/risk: same article, 'grades 1 and 2 were associated with satisfactory outcome whereas grades 3-5 ... unsatisfactory ... (P<0.001)'.
- **3**: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/ · Criteria: PMC4394844, 'Classification of Perianal Fistulae', Grade 3 = 'simple transphincteric fistulae'. Management/outcome: same article — incontinence '>50%' with laying-open of complex fistulas, and 'grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'.
- **4**: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/ · Criteria: PMC4394844, Grade 4 = 'a more complicated transphincteric process with a secondary tract or abscess'; ischioanal/ischiorectal-fossa site corroborated by WebSearch summaries of St James / Morris 2000 on pmc.ncbi.nlm.nih.gov. Management/outcome: same article — complex fistulas need sphincter-preserving/staged surgery (lay-open incontinence '>50%') and 'grades 3-5 ... unsatisfactory outcome ... (P<0.001)'.
- **5**: Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas (St James University Hospital) (2000) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4394844/ · Criteria: PMC4394844, Grade 5 = 'a complicated abscess with a supra or translevator component'. Management/outcome: same article — complex/high disease needs sphincter-preserving/staged surgery (lay-open incontinence '>50%') and 'grades 3-5 were associated with unsatisfactory outcome ... (P<0.001)'.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/stjames-fistula · API JSON: https://radcommons.laudos.ai/api/v1/systems/stjames-fistula · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Borrmann — Borrmann classification of advanced gastric carcinoma

> Classifies advanced gastric carcinoma by macroscopic morphology.

**Status:** current · **Organ:** Gastrointestinal · **Issuing body:** Gastric pathology consensus · **Version:** current · **Year:** 1926

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, Fluoroscopy
- Primary source: Song XH, Zhang WH, Liu K, et al.. Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7427284/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, polypoid | Polypoid, mass-forming tumor that is sharply demarcated from the adjacent normal mucosa. | — | Grouped with type II as the more favorable category: combined type I and II 3-year and 5-year survival of 67.8% and 57.2% in the cited cohort (the best in that series). | PMC7427284 (Song et al., World J Surg Oncol 2020), 'Classification of advanced gastric cancer according to Borrmann type' section (criteria) and Results (survival); descriptor corroborated by PMC3418539. | ✓ |
| II | Type II, ulcerated with raised margins | Ulcerated carcinoma whose margins are sharply demarcated and raised/elevated, without infiltration into the surrounding wall. | — | Reported jointly with type I (type I plus II): 3-year and 5-year survival of 67.8% and 57.2% in the cited cohort (most favorable group). | PMC7427284, 'Classification of advanced gastric cancer according to Borrmann type' section (criteria) and Results (survival). | ✓ |
| III | Type III, ulcerated and infiltrating | Ulcerated carcinoma with indefinite, ill-defined margins that infiltrates into the surrounding gastric wall. | — | Intermediate-to-poor: 3-year and 5-year survival of 59.0% and 48.5% in the cited cohort (lower than type I plus II); types III and IV are described as showing more aggressive behavior. | PMC7427284, classification section (criteria) and Results/Discussion (survival). | ✓ |
| IV | Type IV, diffusely infiltrating (linitis plastica) | Carcinoma with diffuse infiltration of the gastric wall, in which ulceration is generally not a feature; referred to as linitis plastica when most of the wall is involved (notably in signet-ring-cell carcinoma). | — | Worst prognosis: 3-year and 5-year survival of 37.9% and 28.9% in the cited cohort (lowest in the series). | PMC7427284, classification section and Results/Discussion (survival); linitis plastica equivalence corroborated by PMC3418539, 'Early and advanced gastric carcinoma' section. | ✓ |

### Per-category citations
- **I**: Song XH, Zhang WH, Liu K, et al.. Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7427284/ · PMC7427284 (Song et al., World J Surg Oncol 2020), 'Classification of advanced gastric cancer according to Borrmann type' section (criteria) and Results (survival); descriptor corroborated by PMC3418539.
- **II**: Song XH, Zhang WH, Liu K, et al.. Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7427284/ · PMC7427284, 'Classification of advanced gastric cancer according to Borrmann type' section (criteria) and Results (survival).
- **III**: Song XH, Zhang WH, Liu K, et al.. Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7427284/ · PMC7427284, classification section (criteria) and Results/Discussion (survival).
- **IV**: Song XH, Zhang WH, Liu K, et al.. Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7427284/ · PMC7427284, classification section and Results/Discussion (survival); linitis plastica equivalence corroborated by PMC3418539, 'Early and advanced gastric carcinoma' section.

## Cross-references
- _shared boundary_ → [Siewert — Siewert classification of gastroesophageal junction adenocarcinoma](https://radcommons.laudos.ai/systems/siewert.md) — Borrmann grades gastric carcinoma morphology; Siewert localizes gastroesophageal-junction adenocarcinoma.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/borrmann · API JSON: https://radcommons.laudos.ai/api/v1/systems/borrmann · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# MaRIA — Magnetic Resonance Index of Activity for Crohn disease

> Continuous segmental MR-enterography activity index for ileocolonic Crohn disease using wall thickness, noise-corrected relative contrast enhancement, mural edema and ulceration. The validated segmental thresholds are nested (7 or more active; 11 or more severe/ulcerative), do not apply to the global sum and cannot select treatment or replace complication reporting.

**Status:** current · **Organ:** Gastrointestinal · **Issuing body:** Rimola et al. / ECCO / ESGAR / ESP / IBUS · **Version:** 2009 original; 2018 validation guidance; 2024-2025 monitoring context · **Year:** 2009

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Rimola J, Rodriguez S, Garcia-Bosch O, et al.. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease (MaRIA) (2009) — https://pubmed.ncbi.nlm.nih.gov/19136510/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Calculate the original score per segment from measured components. Thresholds 7 and 11 are inclusive and segmental; severe is nested inside active. Keep sMaRIA, complications, fibrosis, prognosis and treatment separate.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| inactive | Segmental MaRIA below 7, inactive threshold state | Inactive threshold state: segmental MaRIA below 7. Calculate original segmental MaRIA as 1.5 x wall thickness in mm + 0.02 x noise-corrected relative contrast enhancement + 5 x mural edema present + 10 x ulceration present; the 7 cutoff applies to a segment, not the global sum. | Use the result as one objective imaging input alongside symptoms, biomarkers, endoscopy when indicated, complications and prior therapy. A segment below 7 does not independently justify treatment de-escalation or prove whole-patient, mucosal or transmural remission. | A score below 7 did not meet the validated active-endoscopic-lesion threshold in the scored segment. It does not exclude activity in unscored or poorly distended bowel, fibrosis, stricture, penetrating disease or future relapse and is not a personal prognosis. | Rimola et al. 2009, PMID 19136510 and DOI 10.1136/gut.2008.167957, derivation variables and endoscopic reference; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, section 4.3 and segmental cutoff below 7; Yanai et al. 2025, DOI 10.1093/ecco-jcc/jjaf107, current score context. | ✓ |
| active | Segmental MaRIA 7 or more, active inflammation | Active inflammation: segmental MaRIA 7 or more. The threshold is inclusive and identifies an endoscopic lesion of any severity; scores of 11 or more remain active and additionally meet the nested severe or ulcerative threshold. Do not apply 7 to the global six-segment sum. | Communicate the active segments, continuous scores, affected lengths and comparison change for multidisciplinary treatment review. The threshold supports objective monitoring but does not choose a drug, dose, escalation, endoscopy interval, admission or operation by itself. | The threshold is associated with active endoscopic lesions in validation cohorts, not with a fixed individual probability of hospitalization, surgery, bowel damage or relapse. Protocol quality, segment distension and complications remain visible. | Rimola et al. 2009, DOI 10.1136/gut.2008.167957, activity model; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, MaRIA at least 7 for active segments and six-segment sum; Bhatnagar et al. 2024, DOI 10.1093/ecco-jcc/jjae042, original-versus-simplified index boundary. | ✓ |
| severe | Segmental MaRIA 11 or more, severe ulcerative activity (nested within active) | Severe ulcerative activity: segmental MaRIA 11 or more. The threshold is inclusive, corresponds to superficial or deep ulceration at the endoscopic reference and is a subset of active disease, so the segment should retain both active and severe states. | Flag the ulcerative activity for timely multidisciplinary correlation and separately report obstruction, strictures, fistulas, abscess or other urgent findings. MaRIA 11 alone is not an emergency, hospitalization, surgery or medication mandate. | The score marks a severe endoscopic phenotype in the scored segment but is not a calibrated personal outcome forecast. It cannot determine fibrosis, penetrating behavior, overall clinical severity or future complication risk without the rest of the examination and clinical course. | Rimola et al. 2009, PMID 19136510, ulceration and severity reference; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, segmental MaRIA at least 11 and ulcerative-lesion performance; Kucharzik et al. and Yanai et al. 2025, DOI 10.1093/ecco-jcc/jjaf106 and jjaf107, current diagnostics and monitoring context. | ✓ |

### Per-category citations
- **inactive**: Rimola J, Rodriguez S, Garcia-Bosch O, et al.. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease (MaRIA) (2009) — https://pubmed.ncbi.nlm.nih.gov/19136510/ · Rimola et al. 2009, PMID 19136510 and DOI 10.1136/gut.2008.167957, derivation variables and endoscopic reference; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, section 4.3 and segmental cutoff below 7; Yanai et al. 2025, DOI 10.1093/ecco-jcc/jjaf107, current score context.
- **active**: Rimola J, Rodriguez S, Garcia-Bosch O, et al.. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease (MaRIA) (2009) — https://pubmed.ncbi.nlm.nih.gov/19136510/ · Rimola et al. 2009, DOI 10.1136/gut.2008.167957, activity model; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, MaRIA at least 7 for active segments and six-segment sum; Bhatnagar et al. 2024, DOI 10.1093/ecco-jcc/jjae042, original-versus-simplified index boundary.
- **severe**: Rimola J, Rodriguez S, Garcia-Bosch O, et al.. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease (MaRIA) (2009) — https://pubmed.ncbi.nlm.nih.gov/19136510/ · Rimola et al. 2009, PMID 19136510, ulceration and severity reference; Sturm et al. 2018, DOI 10.1093/ecco-jcc/jjy114, segmental MaRIA at least 11 and ulcerative-lesion performance; Kucharzik et al. and Yanai et al. 2025, DOI 10.1093/ecco-jcc/jjaf106 and jjaf107, current diagnostics and monitoring context.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2025-07-03 | revised | The ECCO-ESGAR-ESP-IBUS guideline updated multidisciplinary diagnostic and monitoring context for MRE and formal IBD scores without turning a MaRIA threshold into a treatment mandate. | confirmed |
| 2024-04-04 | revised | A current ECCO journal review positioned original MaRIA and sMaRIA as separate validated MRE activity indices and emphasized their different components, time burden and trial-oriented use. | confirmed |
| 2018-08-27 | revised | The ECCO-ESGAR diagnostic guideline summarized the segmental 7 and 11 thresholds, six-segment global sum, performance and original colonic-distension limitation. | confirmed |
| 2009-08-01 | published | MaRIA index published by Rimola et al. in Gut. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/maria-crohn · API JSON: https://radcommons.laudos.ai/api/v1/systems/maria-crohn · Agent index: https://radcommons.laudos.ai/llms.txt

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# Siewert — Siewert classification of gastroesophageal junction adenocarcinoma

> Classifies adenocarcinoma by location relative to the gastroesophageal junction.

**Status:** current · **Organ:** Gastrointestinal · **Issuing body:** Surgical consensus · **Version:** 1998 · **Year:** 1998

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction (Siewert) (1998) — https://doi.org/10.1046/j.1365-2168.1998.00940.x
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Adenocarcinoma of the distal esophagus whose center (epicenter) lies 1 to 5 cm above the anatomical gastroesophageal junction (GEJ); tumor burden is essentially esophageal. | Treated as an esophageal carcinoma: the standard surgical treatment is subtotal esophagectomy with proximal gastrectomy (endoscopic treatment only at very early stage). | Highest distant-metastasis rate of the three types in the cited series (~31.5% vs ~15% for II and ~4.6% for III); overall survival did not differ significantly by Siewert type (median OS ~26.6 months overall), with stage, grade and recurrence the independent OS predictors. | Criteria & figures: PMC5448566 (Cao et al.), Introduction (type I = 1-5 cm above GEJ) and Results/Discussion (metastasis ~31.5%; OS not different by type, median ~26.6 mo; stage/grade/recurrence independent OS factors). Surgery: same source ('subtotal esophagectomy and proximal gastrectomy'). | ✓ |
| II | Type II | True junctional (cardia) adenocarcinoma whose center lies within the zone from 1 cm above to 2 cm below the anatomical gastroesophageal junction (GEJ); the most controversial category as it straddles the true junction. | Distal esophagectomy with total gastrectomy is preferred for type II tumors (the source does not specify a lymphadenectomy level for type II). | Intermediate distant-metastasis rate (~15%) and intermediate disease-free survival (~14 months) in the cited series; overall survival did not differ significantly between Siewert types. | Criteria: PMC5448566 (Cao et al.), Introduction (type II = 1 cm above to 2 cm below GEJ). Management & figures: same source ('Distal esophagectomy and total gastrectomy are preferred in type II tumors'; metastasis ~15%; DFS ~14 mo; OS not different by type). | ✓ |
| III | Type III | Subcardial gastric adenocarcinoma that infiltrates the GEJ/distal esophagus from below, with its center located 2 to 5 cm below the anatomical gastroesophageal junction (GEJ); tumor burden is essentially gastric. | Treated as a gastric carcinoma: total gastrectomy with D1 (gastric-cancer-protocol) lymph node dissection. | Lowest distant-metastasis rate (~4.6%) and the longest disease-free survival (~20.8 months) of the three types in the cited series, though overall survival did not differ significantly by Siewert type (p=0.5). | Criteria: PMC5448566 (Cao et al.), Introduction (type III = 2-5 cm below GEJ). Management & figures: same source ('total gastrectomy and D1 lymph node dissection' for type III; metastasis ~4.6%; DFS ~20.8 mo; OS not different by type). | ✓ |

### Per-category citations
- **I**: Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction (Siewert) (1998) — https://doi.org/10.1046/j.1365-2168.1998.00940.x · Criteria & figures: PMC5448566 (Cao et al.), Introduction (type I = 1-5 cm above GEJ) and Results/Discussion (metastasis ~31.5%; OS not different by type, median ~26.6 mo; stage/grade/recurrence independent OS factors). Surgery: same source ('subtotal esophagectomy and proximal gastrectomy').
- **II**: Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction (Siewert) (1998) — https://doi.org/10.1046/j.1365-2168.1998.00940.x · Criteria: PMC5448566 (Cao et al.), Introduction (type II = 1 cm above to 2 cm below GEJ). Management & figures: same source ('Distal esophagectomy and total gastrectomy are preferred in type II tumors'; metastasis ~15%; DFS ~14 mo; OS not different by type).
- **III**: Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction (Siewert) (1998) — https://doi.org/10.1046/j.1365-2168.1998.00940.x · Criteria: PMC5448566 (Cao et al.), Introduction (type III = 2-5 cm below GEJ). Management & figures: same source ('total gastrectomy and D1 lymph node dissection' for type III; metastasis ~4.6%; DFS ~20.8 mo; OS not different by type).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/siewert · API JSON: https://radcommons.laudos.ai/api/v1/systems/siewert · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# NI-RADS — ACR Neck Imaging Reporting and Data System

> Post-definitive-treatment surveillance framework assigning primary-site and neck categories separately: 0 incomplete, 1 no evidence, 2 low suspicion with primary 2a/2b branches, 3 high suspicion and 4 proven or definite progression. P-x/N-x and unknown-primary states are qualifiers, not ordinal scores. The category supports standardized next-step communication but does not diagnose recurrence, collapse P and N, or supply a universal patient-level recurrence probability.

**Status:** current · **Organ:** Head and Neck · **Issuing body:** American College of Radiology · **Version:** 2018 CT/PET framework; MRI v2025 current release · **Year:** 2025

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI, PET/CT
- Primary source: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Return separate P and N assessments, preserve modality/release, and never turn suspicion into pathology, a universal recurrence probability or an autonomous treatment order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Incomplete comparison | Incomplete comparison for a new posttreatment baseline when a required prior examination is known or expected to become available. This is distinct from P-x or N-x technical nonassessability. | Obtain the required prior study and issue an addendum after comparison. Do not treat category 0 as a negative surveillance result, low suspicion or a reason to restart the surveillance interval. | Category 0 carries no recurrence-risk meaning because the comparison needed for classification is incomplete. It must not be converted into a numerical probability or combined with the other axis. | ACR NI-RADS MRI v2025 Assessment Categories table, category 0 row and x-qualifier footnotes; official current-release index. | ✓ |
| 1 | No evidence of recurrence | No evidence of recurrence at the assessed primary site or neck: normal or expected posttreatment anatomy and change without a suspicious focal mucosal, deep or nodal abnormality. | Continue routine surveillance according to tumor type, treatment, elapsed time and the institutional care pathway. Return primary-site and neck assessments separately even when both are category 1. | Category 1 communicates no current imaging suspicion, not zero lifetime or microscopic recurrence risk. No universal negative predictive value can be transferred across sites, modalities, timepoints and populations. | ACR NI-RADS MRI v2025 Assessment Categories table, primary-site and neck category 1 rows; Aiken et al. 2018 CT/PET framework. | ✓ |
| 2 | Low suspicion | Low suspicion. At the primary site, 2a is a focal non-mass-like mucosal enhancement or focal reduced-diffusion abnormality suitable for direct inspection, whereas 2b is a deep ill-defined nonnodular abnormality. In the neck, category 2 includes equivocal residual enhancement or uptake, a new or enlarging node without definitively malignant morphology, or meaningful modality discordance. | For primary 2a, recommend direct visual or endoscopic inspection. For primary 2b, recommend short-interval imaging, with MRI favored when perineural or skull-base disease is the concern. For neck 2, recommend short-interval imaging integrating morphology, diffusion, FDG activity and trajectory. Do not collapse these branches into one generic action. | Category 2 is a qualitative low-suspicion state spanning distinct mucosal, deep and nodal patterns; it has no single portable recurrence percentage. The branch, modality, timing and treated cancer determine the useful context. | ACR NI-RADS MRI v2025 Assessment Categories table, primary-site 2a and 2b rows and neck category 2 row; Aiken et al. 2018 for CT/PET-linked management. | ✓ |
| 3 | High suspicion | High suspicion based on a discrete enhancing mass matching the tumor bed, intense focal FDG uptake compatible with tumor, progressive perineural abnormality, or a highly suspicious and concordantly progressive nodal finding. | Recommend image-guided or clinical biopsy when clinically indicated and technically feasible, with multidisciplinary review when the site is inaccessible, biopsy is contraindicated or radiologic and clinical evidence is otherwise decisive. Category 3 remains suspicion rather than proof. | Category 3 has high imaging suspicion but does not equal pathology and cannot provide an individual recurrence probability. Inflammation, treatment effect, second malignancy and technical discordance remain possible explanations. | ACR NI-RADS MRI v2025 Assessment Categories table, primary-site and neck category 3 rows; 2018 ACR white paper for linked biopsy recommendation. | ✓ |
| 4 | Pathologically proven or definite progression | Pathologically proven residual or recurrent tumor, or definite radiologic progression supported by concordant clinical evidence when the multidisciplinary team determines that tissue confirmation is unnecessary or infeasible. | Route to multidisciplinary clinical management while separately reporting exact site, extent, proof basis and complications. Category 4 does not select a systemic regimen, operation, radiation plan or prognosis. | Category 4 records known or definite disease rather than a probabilistic suspicion band, but disease extent, treatment options and patient outcome still cannot be inferred from the numeral alone. | ACR NI-RADS MRI v2025 Assessment Categories table, category 4 rows; Aiken et al. 2018 for known-recurrence management context. | ✓ |

### Per-category citations
- **0**: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf · ACR NI-RADS MRI v2025 Assessment Categories table, category 0 row and x-qualifier footnotes; official current-release index.
- **1**: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf · ACR NI-RADS MRI v2025 Assessment Categories table, primary-site and neck category 1 rows; Aiken et al. 2018 CT/PET framework.
- **2**: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf · ACR NI-RADS MRI v2025 Assessment Categories table, primary-site 2a and 2b rows and neck category 2 row; Aiken et al. 2018 for CT/PET-linked management.
- **3**: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf · ACR NI-RADS MRI v2025 Assessment Categories table, primary-site and neck category 3 rows; 2018 ACR white paper for linked biopsy recommendation.
- **4**: Aiken AH, et al.. Neck Imaging Reporting and Data System MRI: A Standardized Template for Posttreatment Head and Neck Cancer Surveillance (2025) — https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/NI-RADS/NIRADS-MRI-2025-Assessment-Categories.pdf · ACR NI-RADS MRI v2025 Assessment Categories table, category 4 rows; Aiken et al. 2018 for known-recurrence management context.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-23 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-21 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-20 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-19 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-18 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-17 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-16 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-15 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-07-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-06-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-06-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-06-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-06-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2025-07-01 | revised | ACR published the current MRI v2025 template and assessment-category table, including category 0, separate primary and neck axes, primary 2a/2b branches and x qualifiers. | confirmed |
| 2018-08-01 | published | The ACR NI-RADS Committee published the CT and PET/CT posttreatment surveillance white paper with linked primary-site and neck categories and management recommendations. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/ni-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/ni-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# AAST Kidney OIS — AAST Kidney Organ Injury Scale

> Current per-kidney grade I-V traumatic renal injury scale using the highest imaging, operative or pathologic finding. The 2025 revision adds explicit laceration and hematoma measurements, separates contained vascular injury from active bleeding, regrades collecting-system injury, defines pararenal hematoma and multifragmented kidney, and does not prescribe treatment from grade alone.

**Status:** current · **Organ:** Kidney · **Issuing body:** American Association for the Surgery of Trauma · **Version:** 2025 revision · **Year:** 2025

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply the 2025 per-kidney highest-finding algorithm, preserve source provenance and version, and keep anatomic grade separate from hemodynamics and treatment.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | 2025 grade I is a subcapsular hematoma under 3.5 cm without active bleeding, or a renal parenchymal contusion without laceration. Apply the highest qualifying finding per kidney; a laceration, larger hematoma measurement, active bleeding or another higher-grade feature overrides grade I. | In a hemodynamically stable or stabilized patient, renal-preserving nonoperative care with clinical and laboratory monitoring is generally appropriate for isolated low-grade anatomy. The code does not replace trauma assessment: instability, ongoing blood loss, associated injury or clinical deterioration requires escalation independent of the grade. | Grade I is the least anatomically advanced 2025 category, but it provides no universal probability of delayed bleeding, renal-function loss or length of stay. Mechanism, anticoagulation, solitary kidney, associated trauma and physiology remain relevant, and a low renal grade does not exclude a dangerous injury elsewhere. | Keihani et al. 2025, PMID 39836096, current AAST update; Jeon 2025, DOI 10.64961/kjir.2025.00052, Table 1 grade I and measurement footnotes; WSES-AAST 2019 and current EAU guidance for stable-patient management boundary. | ✓ |
| II | Grade II | 2025 grade II includes renal parenchymal laceration length under 2.5 cm or hematoma rim distance under 3.5 cm without active bleeding. Laceration length is the longest length on one axial image; HRD is measured perpendicular from renal parenchyma to the bulk hematoma border within the kidney's superior-inferior extent. | Stable or stabilized patients are usually managed nonoperatively with renal-preserving observation and reassessment tailored to the whole trauma. Do not order embolization or surgery from grade II alone. Escalate when physiology, transfusion need, expanding hemorrhage, new vascular findings, associated injury or another clinical complication supplies an independent indication. | Grade II remains low-grade anatomy but is not risk-free and is not a validated bedside probability. Measurement quality near 2.5 cm or 3.5 cm can change the code, and outcomes depend on physiology, mechanism and comorbidity. Preserve uncertainty rather than presenting a threshold-adjacent measurement as exact. | Keihani et al. 2025 and Jeon 2025 Table 1, grade II thresholds and axial measurement definitions; AAST official OIS revision page confirms 2025 as current; WSES-AAST and EAU for nonoperative stable-patient context. | ✓ |
| III | Grade III | 2025 grade III is assigned for any of: parenchymal laceration length at least 2.5 cm; HRD at least 3.5 cm without active bleeding; partial kidney infarction; a contained vascular injury without active bleeding such as pseudoaneurysm, arteriovenous fistula, dissection, thrombosis, intimal flap or mural hematoma; or laceration into the collecting system and/or urinary extravasation. | Hemodynamically stable or stabilized grade-III anatomy can often receive nonoperative renal-preserving care. Evaluate a contained vascular lesion, hematoma trajectory and clinical bleeding for selective angiography or embolization, and initially observe many parenchymal urinary leaks while assessing for persistent leak, infection, obstruction or suspected proximal avulsion. Management follows anatomy and physiology, not the Roman numeral alone. | This category is heterogeneous: a length-threshold laceration, contained vascular lesion, partial infarct and urinary leak do not share one complication probability. Active bleeding would move the anatomy to grade IV, while a collecting-system leak is now grade III rather than IV. Report the qualifying feature because it carries more actionable risk information than the grade token. | Keihani et al. 2025; Jeon 2025 Table 1 grade III and contained-vascular definitions; Kozar et al. 2018 for predecessor comparison; AUA 2020, WSES-AAST 2019, EAST 2023 and EAU for bleeding and urinary-leak management context, interpreted by anatomy because those guidelines predate the 2025 remapping. | ✓ |
| IV | Grade IV | 2025 grade IV is assigned for active bleeding from the kidney; pararenal extension of hematoma; complete or near-complete kidney infarction without active bleeding; a multifragmented kidney without active bleeding; or complete or near-complete ureteropelvic-junction disruption. Pararenal extension and MFK require the scale's explicit definitions, not subjective use of large or shattered. | This grade requires urgent multidisciplinary trauma, urology and interventional-radiology assessment, but it still does not mandate one treatment. Stable or stabilized patients may be candidates for nonoperative renal preservation, selective embolization for active bleeding, or drainage and reconstruction for specific urinary injury; refractory hemodynamic instability or failed hemorrhage control can require immediate surgery. | Grade IV identifies major anatomy and a higher likelihood of intervention than low-grade injury, but it is not an individual mortality or nephrectomy calculator. Active bleeding, avascular kidney, pararenal spread, MFK without bleeding and UPJ disruption have different mechanisms and consequences. State the qualifying feature, hemodynamics, transfusion and associated injuries. | Keihani et al. 2025; Jeon 2025 Table 1 grade IV and footnote definitions of active bleeding, pararenal hematoma and MFK; AUA, WSES-AAST, EAST and EAU management guidance with explicit warning that legacy grade-number recommendations require anatomic remapping after 2025. | ✓ |
| V | Grade V | 2025 grade V is assigned for main renal artery or vein laceration or transection with active bleeding, complete or near-complete kidney infarction with active bleeding, or a multifragmented kidney with active bleeding. MFK means at least three injured parenchymal segments separated by fluid or blood; active bleeding distinguishes the grade-V MFK pattern from grade IV. | Provide immediate hemorrhage-control and renal-salvage assessment based on hemodynamic response and associated trauma. Unstable patients may require operative control including nephrectomy when repair is not feasible; selected stabilized patients at experienced centers can undergo endovascular or renal-preserving strategies. Grade V must never be converted automatically into nephrectomy, futility or a treatment limitation. | Grade V is the most anatomically advanced current category and signals substantial hemorrhagic and renal-loss concern, yet no single outcome probability applies to all three qualifying patterns. Survival and salvage depend on physiology, ischemia, associated injury, time to control and expertise. Do not import grade-V rates from a 2018 cohort without reclassifying its anatomy. | Keihani et al. 2025; Jeon 2025 Table 1 grade V and MFK/active-bleeding definitions; WSES-AAST, EAST and current EAU guidance for physiology-led hemorrhage control and selected renal preservation. | ✓ |

### Per-category citations
- **I**: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/ · Keihani et al. 2025, PMID 39836096, current AAST update; Jeon 2025, DOI 10.64961/kjir.2025.00052, Table 1 grade I and measurement footnotes; WSES-AAST 2019 and current EAU guidance for stable-patient management boundary.
- **II**: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/ · Keihani et al. 2025 and Jeon 2025 Table 1, grade II thresholds and axial measurement definitions; AAST official OIS revision page confirms 2025 as current; WSES-AAST and EAU for nonoperative stable-patient context.
- **III**: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/ · Keihani et al. 2025; Jeon 2025 Table 1 grade III and contained-vascular definitions; Kozar et al. 2018 for predecessor comparison; AUA 2020, WSES-AAST 2019, EAST 2023 and EAU for bleeding and urinary-leak management context, interpreted by anatomy because those guidelines predate the 2025 remapping.
- **IV**: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/ · Keihani et al. 2025; Jeon 2025 Table 1 grade IV and footnote definitions of active bleeding, pararenal hematoma and MFK; AUA, WSES-AAST, EAST and EAU management guidance with explicit warning that legacy grade-number recommendations require anatomic remapping after 2025.
- **V**: Keihani S, Tominaga GT, Matta R, et al.. Kidney organ injury scaling: 2025 update (2025) — https://pubmed.ncbi.nlm.nih.gov/39836096/ · Keihani et al. 2025; Jeon 2025 Table 1 grade V and MFK/active-bleeding definitions; WSES-AAST, EAST and current EAU guidance for physiology-led hemorrhage control and selected renal preservation.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-01-20 | revised | AAST published the current multidisciplinary kidney OIS revision with 2.5 cm laceration and 3.5 cm hematoma thresholds, regraded urinary extravasation, explicit bleeding and MFK rules, separate per-kidney grading and no multiple-injury upgrade. | confirmed |
| 2018-12-01 | revised | The 2018 AAST revision incorporated CT vascular injury, active bleeding and collecting-system findings; it is retained as the immediate predecessor, not the current renal scale. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aast-kidney · API JSON: https://radcommons.laudos.ai/api/v1/systems/aast-kidney · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Bosniak — Bosniak classification of cystic renal masses, version 2019

> Classification of cystic renal masses into classes by likelihood of malignancy.

**Status:** current · **Organ:** Kidney · **Issuing body:** Radiology consensus (Silverman et al.) · **Version:** 2019 · **Year:** 2019

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Class I | Well-defined cystic mass with a thin (2 mm or less) smooth wall that may enhance; homogeneous simple-fluid attenuation (about -9 to 20 HU on CT); no septa, no calcification, and no nodules. | No imaging follow-up indicated; may be described simply as a cyst. | Considered universally benign (essentially 0% malignancy). | Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak I' | ✓ |
| II | Class II | Cystic masses with a thin (2 mm or less) smooth wall and few (1-3) thin (2 mm or less) septa, where wall and septa may enhance and calcification of any type is allowed; also includes several homogeneous categories such as masses about -9 to 20 HU, homogeneous hyperattenuating masses 70 HU or greater at noncontrast CT, homogeneous nonenhancing masses above 20 HU at renal-mass-protocol CT, and homogeneous masses about 21-30 HU at portal venous phase. | No follow-up indicated for typical cases; treated as benign. | Reported malignancy rate is below 1% (may be as low as 0%). | Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak II' | ✓ |
| IIF | Class IIF | Cystic masses with a smooth, minimally thickened (3 mm) enhancing wall, or smooth minimal (3 mm) thickening of one or more enhancing septa, or many (4 or more) smooth thin (2 mm or less) enhancing septa. | Imaging surveillance (follow-up) is recommended; observation is considered safe over a roughly 5-year period. | Reported malignancy rates are wide, in the range of 0% to 38%; the article notes that of 954 stable IIF masses only 54 were resected, of which 9 (about 17%) were malignant, while about 94% (900 of 954) were not resected and did not progress. | Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2 and accompanying note; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak IIF' | ✓ |
| III | Class III | Cystic masses with one or more enhancing thick (4 mm or greater in width) or enhancing irregular (3 mm or smaller obtusely-margined convex protrusions) walls or septa. | Management varies between institutions, with resection/ablation historically standard and active surveillance increasingly advocated; choice depends on lesion size, patient comorbidities, and surgeon preference. | Indeterminate; approximately half of resected Bosniak III masses are malignant, with individual series ranging from about 25% to 100% (conversely about half are benign). | Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; irregular definition Table 3; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak III' | ✓ |
| IV | Class IV | Cystic masses with one or more enhancing nodules, defined as a focal enhancing convex protrusion of any size with acute margins, or a 4 mm or larger convex protrusion with obtuse margins relative to the wall or a septum. | Treatment (resection or ablation) is recommended in most cases when patient characteristics allow; observation is discussed only for selected patients. | Approximately 90% malignant, with individual series ranging from about 56% to 100% (a minority are benign). | Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; nodule definition Table 3; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak IV' | ✓ |

### Per-category citations
- **I**: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646 · Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak I'
- **II**: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646 · Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak II'
- **IIF**: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646 · Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2 and accompanying note; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak IIF'
- **III**: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646 · Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; irregular definition Table 3; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak III'
- **IV**: Silverman SG, Pedrosa I, Ellis JH, et al.. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment (2019) — https://doi.org/10.1148/radiol.2019182646 · Silverman et al., Radiology 2019 (PMC6677285), CT/MRI criteria Table 2; nodule definition Table 3; corroborated radiologyassistant.nl Bozniak-2019 section 'Bosniak IV'

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2019-05-01 | revised | Bosniak version 2019 update proposal published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bosniak-2019 · API JSON: https://radcommons.laudos.ai/api/v1/systems/bosniak-2019 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# VUR — Vesicoureteral reflux grading

> Grades vesicoureteral reflux on voiding cystourethrography.

**Status:** current · **Organ:** Kidney · **Issuing body:** International Reflux Study Committee · **Version:** 1985 · **Year:** 1985

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Fluoroscopy
- Primary source: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | Reflux into a non-dilated ureter only (urine refluxes solely into the ureter, which is not dilated). | Lowest-risk grade: conservative observation with the goal of keeping urine sterile; continuous antibiotic prophylaxis individualized/selective (e.g. infants or recurrent febrile UTI) rather than routine, given high spontaneous-resolution rates. | High spontaneous resolution: about 75% (range 70-80%) of grade I-II VUR resolves spontaneously by age 5. | NBK563262 ('about 75% (70% to 80%) of children with grade I and II VUR will spontaneously resolve ... by age 5'); corroborated by en.wikipedia Vesicoureteral_reflux 'Severity'. | ✓ |
| II | Grade II | Reflux reaching the renal pelvis and calyces (ureter and pelvis) without dilatation. | Conservative/low-grade approach: observation with sterile-urine maintenance; antibiotic prophylaxis individualized rather than uniformly applied. | Favorable: about 75% (range 70-80%) of grade I-II VUR resolves spontaneously by age 5. | NBK563262 ('about 75% (70% to 80%) of children with grade I and II VUR will spontaneously resolve ... by age 5'). | ✓ |
| III | Grade III | Mild-to-moderate dilatation of the ureter and pyelocalyceal system with only mild/minimal blunting of the calyceal fornices. | Lower end of 'high-grade': continuous antibiotic prophylaxis is generally recommended; endoscopic subureteric injection considered if intervention is needed and breakthrough infections occur. | Moderate resolution: grade III-IV resolves spontaneously in roughly 60-70% over 5 years when reflux is unilateral and detected before age 2. | NBK563262 (grade III = mildly dilated ureter/pelvocalyceal system, minimal calyceal blunting; 'for grades III and IV ... VUR will resolve in 60% to 70% over 5 years' if unilateral and found before age 2; prophylaxis, endoscopic injection). | ✓ |
| IV | Grade IV | Moderately tortuous, mildly-to-moderately dilated ureter with dilatation of the renal pelvis and calyces and blunting of the calyces, while the papillary impressions are still visible. | High-grade: antibiotic prophylaxis typically recommended; surgical correction (ureteral reimplantation, ~98-99% success) or endoscopic injection (~59% success) for recurrent/breakthrough infection or non-resolution. | Lower spontaneous resolution (grade III-IV ~60-70% over 5 years only if unilateral and detected before age 2); open/robotic reimplantation is highly successful (~98-99%), while endoscopic injection succeeds in ~59%. | NBK563262 (grade IV = tortuous moderately dilated ureter, calyceal blunting with preserved papillary impression; grade III-IV 60-70% over 5 yr if unilateral/early; reimplantation 98-99%, endoscopic grade IV 59%). | ✓ |
| V | Grade V | Severely (grossly) dilated, very tortuous ureter with marked pyelocalyceal dilatation and loss of the papillary impressions/fornices. | Highest-grade: surgical intervention (open ureteral reimplantation) is usually preferred; antibiotic prophylaxis for very young infants pending repair; endoscopic injection an alternative (~62% success). | Spontaneous resolution without surgery is rare; open/robotic reimplantation success is around 80% (lower than the 98-99% seen in lower grades), while endoscopic injection succeeds in ~62%. | NBK563262 (grade V = grossly dilated tortuous ureter, loss of papillary impressions; 'spontaneous resolution without surgical intervention is rare'; reimplantation ~80%, endoscopic 62%). | ✓ |

### Per-category citations
- **I**: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714 · NBK563262 ('about 75% (70% to 80%) of children with grade I and II VUR will spontaneously resolve ... by age 5'); corroborated by en.wikipedia Vesicoureteral_reflux 'Severity'.
- **II**: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714 · NBK563262 ('about 75% (70% to 80%) of children with grade I and II VUR will spontaneously resolve ... by age 5').
- **III**: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714 · NBK563262 (grade III = mildly dilated ureter/pelvocalyceal system, minimal calyceal blunting; 'for grades III and IV ... VUR will resolve in 60% to 70% over 5 years' if unilateral and found before age 2; prophylaxis, endoscopic injection).
- **IV**: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714 · NBK563262 (grade IV = tortuous moderately dilated ureter, calyceal blunting with preserved papillary impression; grade III-IV 60-70% over 5 yr if unilateral/early; reimplantation 98-99%, endoscopic grade IV 59%).
- **V**: Lebowitz RL, Olbing H, Parkkulainen KV, et al.. International system of radiographic grading of vesicoureteric reflux (1985) — https://doi.org/10.1007/BF02388714 · NBK563262 (grade V = grossly dilated tortuous ureter, loss of papillary impressions; 'spontaneous resolution without surgical intervention is rare'; reimplantation ~80%, endoscopic 62%).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/vur-reflux · API JSON: https://radcommons.laudos.ai/api/v1/systems/vur-reflux · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# AAST Liver — AAST Liver Organ Injury Scale

> Current grade I-V anatomic liver-trauma scale using the highest imaging, operative or pathologic finding across hematoma, laceration, parenchymal disruption, contained or free active bleeding and juxtahepatic venous injury. Hemodynamic status, associated injuries and resources remain separate management axes; grade alone neither mandates operation nor supplies an individual outcome probability.

**Status:** current · **Organ:** Liver · **Issuing body:** American Association for the Surgery of Trauma · **Version:** 2018 revision; WSES care boundary reviewed through 2020 · **Year:** 2018

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, Surgery, Pathology
- Primary source: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Use the highest current 2018 anatomic criterion, expose measurements and bleeding location, and keep hemodynamics and treatment as explicit separate axes.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | Subcapsular hematoma involving less than 10% of liver surface area and/or a capsular tear or parenchymal laceration less than 1 cm deep. Use the highest supported imaging, operative or pathologic finding. | In a hemodynamically stable patient without another indication for laparotomy, nonoperative management with appropriate monitoring is generally favored. Hemodynamic deterioration, associated injury and resource availability override the apparently low anatomic grade. | Grade I describes limited anatomic injury but does not guarantee benign clinical course or provide an individual bleeding, transfusion, complication or mortality probability. | Kozar et al. 2018, DOI 10.1097/TA.0000000000002058, revised liver OIS grade I row and highest-grade footnote; Coccolini et al. 2020, PMC7106618, nonoperative-management principles. | ✓ |
| II | Grade II | Subcapsular hematoma involving 10-50% of surface area, intraparenchymal hematoma less than 10 cm in diameter, and/or laceration 1-3 cm deep and 10 cm or less in length. Exact threshold measurements must be preserved. | Stable patients are usually considered for nonoperative management. Arterial blush or pseudoaneurysm can support angiography and angioembolization consideration in an equipped center, but grade II itself is not an embolization or operation order. | Grade II remains a lower anatomic tier, yet physiology and associated injuries are stronger immediate management determinants. No single embolization-success or nonoperative-failure percentage applies to every patient. | Kozar et al. 2018, current grade II hematoma and laceration thresholds; WSES 2020 sections on stable-patient nonoperative management and angioembolization. | ✓ |
| III | Grade III | Subcapsular hematoma greater than 50% or ruptured; intraparenchymal hematoma 10 cm or larger or ruptured; laceration greater than 3 cm deep; and/or contained hepatic vascular injury or active bleeding contained within liver parenchyma. | Nonoperative management can remain appropriate when hemodynamically stable and adequately monitored, often with interventional-radiology assessment for active arterial bleeding or contained vascular injury. Instability or another operative indication changes the pathway independently of the grade. | Grade III combines several different morphologic branches and therefore is not one calibrated risk state. Contained bleeding, a deep laceration and a large hematoma may have different trajectories despite sharing the numeral. | Kozar et al. 2018, current grade III row including contained vascular injury and active bleeding; WSES 2020, nonoperative and angiography guidance. | ✓ |
| IV | Grade IV | Parenchymal disruption involving 25-75% of one hepatic lobe or one to three Couinaud segments within one lobe, and/or active bleeding extending beyond the liver parenchyma into the peritoneum. | A stable grade IV patient may still undergo nonoperative management in a high-capability setting with close surveillance and angioembolization when indicated. Hemodynamic instability or nonresponse to resuscitation drives urgent operative hemorrhage control, not the grade numeral by itself. | Grade IV signals substantial anatomic injury or free active bleeding, but cannot by itself quantify nonoperative failure, mortality or transfusion need. Physiology, coagulopathy, associated injuries and resources dominate individual risk. | Kozar et al. 2018, grade IV parenchymal-disruption and free-active-bleeding criteria; WSES 2020, stable high-grade nonoperative and unstable operative pathways. | ✓ |
| V | Grade V | Parenchymal disruption involving more than 75% of one hepatic lobe or more than three Couinaud segments within one lobe, and/or juxtahepatic venous injury involving the retrohepatic inferior vena cava or central major hepatic veins. | Urgently integrate physiology, hemorrhage control, vascular anatomy, associated injuries and specialist resources. Selected stable patients may remain in a nonoperative or interventional pathway, whereas instability requires operative damage control; grade V does not prescribe a specific repair. | This is the highest current liver OIS tier, but its branches are heterogeneous and do not yield an individual survival or treatment-success percentage. Juxtahepatic venous injury and extensive parenchymal disruption require explicit description beyond the numeral. | Kozar et al. 2018, current grade V row; WSES 2020 sections on severe liver injury, hemodynamic classification and operative or nonoperative resource requirements. | ✓ |

### Per-category citations
- **I**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Kozar et al. 2018, DOI 10.1097/TA.0000000000002058, revised liver OIS grade I row and highest-grade footnote; Coccolini et al. 2020, PMC7106618, nonoperative-management principles.
- **II**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Kozar et al. 2018, current grade II hematoma and laceration thresholds; WSES 2020 sections on stable-patient nonoperative management and angioembolization.
- **III**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Kozar et al. 2018, current grade III row including contained vascular injury and active bleeding; WSES 2020, nonoperative and angiography guidance.
- **IV**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Kozar et al. 2018, grade IV parenchymal-disruption and free-active-bleeding criteria; WSES 2020, stable high-grade nonoperative and unstable operative pathways.
- **V**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Kozar et al. 2018, current grade V row; WSES 2020 sections on severe liver injury, hemodynamic classification and operative or nonoperative resource requirements.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2020-04-30 | revised | WSES published current management context integrating AAST anatomy with hemodynamic status and resource capability; this did not alter the AAST grade definitions. | confirmed |
| 2018-12-01 | revised | AAST published the current liver OIS revision with explicit CT vascular-injury, active-bleeding and parenchymal-disruption criteria. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aast-liver · API JSON: https://radcommons.laudos.ai/api/v1/systems/aast-liver · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# BCLC — Barcelona Clinic Liver Cancer staging

> Stages hepatocellular carcinoma by tumor burden, liver function, and performance status to guide treatment and prognosis.

**Status:** current · **Organ:** Liver · **Issuing body:** Barcelona Clinic Liver Cancer group · **Version:** 2022 · **Year:** 2022

## Provenance and currency
- Family: algorithm
- Logic type: flat
- Modality: CT, MRI, US
- Primary source: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Stage 0, very early | Very early stage: a single tumor up to 2 cm, no vascular invasion or extrahepatic spread; preserved liver function (Child-Pugh A) and ECOG performance status 0. | Ablation (radiofrequency or microwave) is the usual first option; resection where feasible, and liver transplantation in selected candidates. | Best prognosis: median survival exceeds 5 years. | PMC8866082 (Reig et al., J Hepatol 2022), BCLC 2022 algorithm/summary and treatment-strategy section; criteria corroborated by NCBI Bookshelf NBK569796 BCLC staging table (single <=2 cm, CP A, PS 0). | ✓ |
| A | Stage A, early | Early stage: a solitary tumor of any size, or up to 3 nodules each up to 3 cm, with no macrovascular invasion or extrahepatic spread; preserved liver function (Child-Pugh A-B) and ECOG performance status 0. | Curative options: resection (preferred without clinically significant portal hypertension), ablation for tumors up to 3 cm, or transplant when high recurrence-risk pathology is present. | Favorable prognosis: median survival exceeds 5 years. | PMC8866082, BCLC 2022 algorithm and treatment-strategy section; criteria corroborated by NBK569796 table (single, or <=3 nodules <=3 cm, CP A-B, PS 0). | ✓ |
| B | Stage B, intermediate | Intermediate stage: multinodular hepatocellular carcinoma exceeding early-stage limits, without macrovascular invasion or extrahepatic spread; preserved liver function and ECOG performance status 0. | Transarterial chemoembolization is the reference treatment when liver function is preserved; transplant under extended criteria for selected patients, and systemic therapy for extensive or diffuse bilobar disease unsuitable for chemoembolization. | Median survival around 2.5 years. | PMC8866082, BCLC 2022 algorithm and treatment-strategy section; criteria corroborated by NBK569796 table (multinodular, CP A-B, PS 0). | ✓ |
| C | Stage C, advanced | Advanced stage: macrovascular (portal) invasion and/or extrahepatic spread; preserved or compensated liver function (Child-Pugh A-B) and ECOG performance status 1-2. | First-line systemic therapy: atezolizumab plus bevacizumab is the first choice; tremelimumab plus durvalumab, sorafenib, or lenvatinib are alternatives. | Median survival around 2 years. | PMC8866082, systemic-therapy section; criteria corroborated by NBK569796 table (vascular invasion or extrahepatic spread, CP A-B, PS 1-2). | ✓ |
| D | Stage D, terminal | Terminal stage: end-stage liver function (Child-Pugh C, not transplant-eligible) and/or ECOG performance status 3-4 or major cancer-related symptoms; any tumor burden. | Best supportive and symptomatic care with palliative-care coordination. | Poor prognosis: median survival around 3 months. | PMC8866082, treatment-strategy section; criteria corroborated by NBK569796 table (any tumor, CP C, PS 3-4). | ✓ |

### Per-category citations
- **0**: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/ · PMC8866082 (Reig et al., J Hepatol 2022), BCLC 2022 algorithm/summary and treatment-strategy section; criteria corroborated by NCBI Bookshelf NBK569796 BCLC staging table (single <=2 cm, CP A, PS 0).
- **A**: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/ · PMC8866082, BCLC 2022 algorithm and treatment-strategy section; criteria corroborated by NBK569796 table (single, or <=3 nodules <=3 cm, CP A-B, PS 0).
- **B**: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/ · PMC8866082, BCLC 2022 algorithm and treatment-strategy section; criteria corroborated by NBK569796 table (multinodular, CP A-B, PS 0).
- **C**: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/ · PMC8866082, systemic-therapy section; criteria corroborated by NBK569796 table (vascular invasion or extrahepatic spread, CP A-B, PS 1-2).
- **D**: Reig M, Forner A, Rimola J, et al.. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (2022) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8866082/ · PMC8866082, treatment-strategy section; criteria corroborated by NBK569796 table (any tumor, CP C, PS 3-4).

## Cross-references
- _shared boundary_ → [Couinaud — Couinaud liver segmentation with Brisbane terminology](https://radcommons.laudos.ai/systems/couinaud.md) — BCLC stages HCC for treatment planning; Couinaud localizes the tumor for resection planning.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2022-01-01 | revised | BCLC strategy 2022 update published in the Journal of Hepatology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bclc · API JSON: https://radcommons.laudos.ai/api/v1/systems/bclc · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# CEUS LI-RADS — Contrast-enhanced ultrasound LI-RADS

> Categorization of liver observations on contrast-enhanced ultrasound in patients at risk for HCC.

**Status:** current · **Organ:** Liver · **Issuing body:** American College of Radiology · **Version:** v2017 · **Year:** 2017

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| LR-1 | Definitely benign | Definitely benign at CEUS. Typical entities: simple cyst (no enhancement in any vascular phase), hemangioma (peripheral nodular/globular arterial enhancement with progressive centripetal fill-in), and focal fat deposition or sparing (isoenhancing to liver in all phases). No diagnostic uncertainty. | Return to routine surveillance, typically CEUS or other surveillance imaging in about 6 months. | Definitely benign; effectively 0% probability of malignancy. | PMC7000618 (Terzi et al., 'CEUS LI-RADS: a pictorial review', Insights Imaging 2019), category and management sections for LR-1. | ✓ |
| LR-2 | Probably benign | Probably benign at CEUS. Examples: solid nodule under 10 mm that is isoenhancing to liver in all phases; non-mass-like isoenhancing observation 10 mm or larger; atypically located focal fat deposition or sparing. Causes essentially no diagnostic concern. | Return to routine surveillance, typically repeat surveillance imaging in about 6 months. | Probably benign; very low probability of malignancy. | PMC7000618 category and management sections for LR-2. | ✓ |
| LR-3 | Intermediate probability | Intermediate probability of malignancy (similar chance of being benign vs HCC). Includes any nodule lacking both APHE and washout regardless of size; a nodule under 2 cm without APHE that shows late (>=60 s) and mild washout; or APHE without washout when the nodule is under 10 mm. | Repeat CEUS or alternative contrast imaging (CT or MRI) within about 6 months for re-evaluation. | Intermediate probability of malignancy. | PMC7000618 category and management sections for LR-3. | ✓ |
| LR-4 | Probably HCC | Probably HCC. Per CEUS LI-RADS v2017: nodule 2 cm or larger without APHE but with late (>=60 s) and mild washout; APHE without washout when the nodule is 10 mm or larger; or APHE with late and mild washout when the nodule is under 10 mm. Distinguished from LR-5 chiefly by size/washout combination (no washout, or sub-10 mm). | Multidisciplinary discussion for consensus management; if neither biopsy nor treatment is planned, repeat or alternative diagnostic imaging in about 3 months. | High but not definitive probability of HCC. | PMC7000618 category and management sections for LR-4; corroborated by PMC9929373 (Jiang et al. 2023) Discussion (LR-4 = same conditions as LR-5 but without washout). | ✓ |
| LR-5 | Definitely HCC | Definitely HCC. Nodule 10 mm or larger showing non-rim, non-peripheral-globular arterial-phase hyperenhancement (APHE) combined with LATE (onset >=60 s) and MILD washout. Late/mild washout is the key discriminator from LR-M (which shows early or marked washout). | Treat as HCC; multidisciplinary discussion for consensus management. May justify treatment without biopsy in a suitable lesion. | Definitely HCC. In a CEUS LR-5 meta-analysis, pooled specificity was about 0.93 and sensitivity about 0.71 for HCC. | PMC7000618 category and management sections for LR-5; pooled performance from PMC9929373 (Jiang et al., Quant Imaging Med Surg 2023) Results/Abstract. | ✓ |
| LR-M | Probably or definitely malignant, not HCC specific | Probably or definitely malignant but not specific for HCC (e.g. intrahepatic cholangiocarcinoma, metastasis). Defined by any of: rim (ring-like) APHE; EARLY washout (onset <60 s); or MARKED washout (near-complete loss of enhancement within ~2 min). Early and/or marked washout separates LR-M from LR-5. | Multidisciplinary discussion for consensus management; may include alternative or repeat imaging, biopsy, or treatment. | Probable or definite malignancy that is not HCC-specific. | PMC7000618 category and management sections for LR-M; corroborated by PMC9929373 Introduction (LR-M = probable malignancy but not HCC-specific). | ✓ |
| LR-TIV | Tumor in vein | Definite tumor in vein: unequivocal enhancing soft tissue within the lumen of a portal and/or hepatic vein, identified independently of any coexisting parenchymal mass. Early arterial arrival of enhancement (about the same time as the hepatic artery) favors tumor over bland thrombus. | Multidisciplinary discussion for consensus management; biopsy or biomarker correlation may be used to establish etiology. | Indicates malignant vascular invasion; most are HCC, some intrahepatic cholangiocarcinoma or combined HCC-CCA. Etiology and prognosis track the associated parenchymal lesion (LR-4/5 vs LR-M). | PMC7000618 LR-TIV section ('enhancing tissue within a vein... early arrival time favors tumor in vein'). | ✓ |

### Per-category citations
- **LR-1**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 (Terzi et al., 'CEUS LI-RADS: a pictorial review', Insights Imaging 2019), category and management sections for LR-1.
- **LR-2**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 category and management sections for LR-2.
- **LR-3**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 category and management sections for LR-3.
- **LR-4**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 category and management sections for LR-4; corroborated by PMC9929373 (Jiang et al. 2023) Discussion (LR-4 = same conditions as LR-5 but without washout).
- **LR-5**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 category and management sections for LR-5; pooled performance from PMC9929373 (Jiang et al., Quant Imaging Med Surg 2023) Results/Abstract.
- **LR-M**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 category and management sections for LR-M; corroborated by PMC9929373 Introduction (LR-M = probable malignancy but not HCC-specific).
- **LR-TIV**: Lyshchik A, Kono Y, Dietrich CF, et al.. CEUS LI-RADS: contrast-enhanced ultrasound Liver Imaging Reporting and Data System (2017) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC7000618 LR-TIV section ('enhancing tissue within a vein... early arrival time favors tumor in vein').

## Cross-references
- _shared boundary_ → [LI-RADS — Liver Imaging Reporting and Data System, CT/MRI v2018](https://radcommons.laudos.ai/systems/li-rads-ct-mri-2018.md) — CEUS LI-RADS applies the LI-RADS framework to contrast-enhanced ultrasound.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/li-rads-ceus · API JSON: https://radcommons.laudos.ai/api/v1/systems/li-rads-ceus · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Couinaud — Couinaud liver segmentation with Brisbane terminology

> Localizes liver parenchyma by portal territories and intersegmental hepatic-vein planes into segments I-VIII, with segment IV optionally resolved as IVa and IVb.

**Status:** current · **Organ:** Liver · **Issuing body:** Couinaud / IHPBA · **Version:** Classic 8-segment model / Brisbane 2000 terminology · **Year:** 1957

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Assign vascular territories, not just clock-face positions. Preserve multiple involved segments, anatomy variants, uncertainty, and the distinction between anatomic localization and treatment planning.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Segment I (caudate) | Caudate territory dorsal to the main portal pedicle and adjacent to the retrohepatic IVC. Segment I commonly receives portal pedicles from both right and left sides and drains directly to the IVC through short hepatic veins. | Report the caudate relationship to the IVC, short hepatic veins, portal pedicles and hilum when intervention is contemplated. Under Brisbane terminology, explicitly add 'with resection of segment 1' or 'extended to segment 1' when it accompanies another named resection. | The I code has no biological prognosis. Its direct IVC drainage and dorsal vascular relationships can affect technical planning, but they do not provide a quantified operative or ablation-risk category. | Couinaud 1999, PMID 10805544, portal plus suprahepatic segmentation; Anatomy of Hepatic Resectional Surgery, PMC4994882, Couinaud segments text and Fig 7; Brisbane context in PMC4786552, segment-1 naming rule. | ✓ |
| II | Segment II (left lateral, superior) | Superior left-sided segment above the transverse left portal plane. In original Couinaud sector terminology II is the left posterior sector; in Brisbane terminology it joins III as the left lateral section, lateral to the falciform/umbilical-fissure division. | Use II for the demonstrated segmental portal territory and state if a lesion crosses into III, IV or I. II plus III constitutes a Brisbane left lateral sectionectomy; a segment number alone does not establish resectability or select an operation. | Segment II carries no intrinsic oncologic or procedural-risk score. Risk depends on lesion extent, vascular and biliary relationships, access, liver reserve and the planned intervention. | IHPBA Brisbane 2000 consensus, DOI 10.1016/S1365-182X(17)30755-4, second- and third-order divisions; PMC4994882, Couinaud segments and Brisbane terminology; PMC4786552, Figs 1-2. | ✓ |
| III | Segment III (left lateral, inferior) | Inferior left-sided segment below the transverse left portal plane. Brisbane groups III with II as the left lateral section, whereas original Couinaud sector terminology groups III with IV in the left anterior or paramedian sector. | Report III from its portal territory and preserve any extension into II, IV or the hilum. II plus III is a Brisbane left lateral section; do not use the original left sector and Brisbane left section names interchangeably. | Segment III is an anatomic location, not a prognosis. The segment label does not quantify surgical morbidity, safe ablation margin, liver-remnant adequacy, or tumor behavior. | IHPBA Brisbane 2000 consensus, second-order left lateral section and third-order segment terminology; PMC4994882, Couinaud segments text explaining the original II versus III/IV sectors and Brisbane II/III versus IV sections. | ✓ |
| IV | Segment IV (left medial, whole or level unresolved) | Whole left medial segment or segment IV involvement for which a superior-versus-inferior subdivision is not resolved. Brisbane places IV between the functional midplane on the right and the falciform/umbilical-fissure division on the left; it can be subdivided into IVa and IVb. | Return IV when the whole segment is involved or IVa/IVb cannot be assigned confidently; otherwise use the resolved subsegment. Describe proximity to the middle hepatic vein, hilar plate, left portal pedicle and bile ducts rather than treating IV as a complete planning statement. | IV conveys location only. Central vascular or hilar relationships may change technical complexity, but the parent code provides no calibrated procedural, liver-failure, or oncologic risk. | Brisbane 2000 consensus, left medial section and segment nomenclature; PMC4994882, Couinaud segments and Brisbane terminology, including variable IVa/IVb branching; PMC4786552, segment-oriented planning context. | ✓ |
| IVa | Segment IVa (left medial, superior) | Superior subdivision of segment IV, above the transverse portal plane within the Brisbane left medial section. IVa/IVb separation follows left portal-pedicle branching and may be indistinct or variable. | Use IVa only when the superior portal territory can be supported on imaging; otherwise retain IV and state uncertainty. Report middle-hepatic-vein, hilar, portal and biliary relationships for intervention planning. | IVa has no independent biological prognosis or validated technical-risk class. Posterosuperior position and vascular relationships must be described directly rather than inferred from the code. | PMC4994882, Couinaud segments text and Fig 5: segment IV may be divided into IVA superiorly and IVB inferiorly, with variable branching; Brisbane 2000 consensus for left medial-section terminology. | ✓ |
| IVb | Segment IVb (left medial, inferior) | Inferior subdivision of segment IV, below the transverse portal plane within the Brisbane left medial section. It corresponds to the inferior medial left-liver territory and includes the quadrate region in conventional surface anatomy. | Use IVb only when the inferior portal territory is resolved; otherwise retain IV. Report relationships to the gallbladder fossa, hilum, segmental portal and biliary branches, and middle hepatic vein when relevant to planning. | IVb is an anatomic descriptor without a calibrated prognosis. Proximity to hilar, biliary or vascular structures is more informative for technical risk than the segment label itself. | PMC4994882, Couinaud segments text and Fig 5 (IVB inferior to the left portal plane and variable subdivision); Brisbane 2000 consensus, left medial section. | ✓ |
| V | Segment V (right anterior, inferior) | Inferior segment of the right anterior section, generally between the middle- and right-hepatic-vein planes and below the transverse right portal plane. V pairs with VIII in the Brisbane right anterior section. | Report V plus any extension across the middle hepatic, right hepatic or transverse portal boundaries. V with VIII forms the right anterior section, but location alone does not determine sectionectomy, ablation, or resectability. | Segment V has no inherent malignancy or procedural-risk value. Actual risk depends on vascular and biliary proximity, lesion size and extent, liver reserve, and the proposed intervention. | Couinaud 1999, portal and hepatic-vein segmentation; Brisbane 2000 consensus, right anterior section; PMC4994882, Couinaud segments text (V inferior, VIII superior); PMC4786552, Figs 1-2. | ✓ |
| VI | Segment VI (right posterior, inferior) | Inferior segment of the right posterior section, posterolateral to the right-hepatic-vein plane and below the transverse right portal plane. VI pairs with VII in the Brisbane right posterior section. | Report VI and any boundary crossing, especially toward V, VII, IVC or the right hepatic vein. VI with VII forms the right posterior section; the code is localization input, not an operative instruction. | Segment VI carries no calibrated patient or procedure risk. Access, portal and hepatic venous anatomy, biliary relationships, lesion burden and functional reserve remain separate determinants. | Brisbane 2000 consensus, right posterior section; PMC4994882, Couinaud segments text (VI inferior, VII superior); PMC4786552, segmental anatomy and resection terminology. | ✓ |
| VII | Segment VII (right posterior, superior) | Superior segment of the right posterior section, posterolateral to the right-hepatic-vein plane and above the transverse right portal plane. VII pairs with VI in the Brisbane right posterior section. | Report VII with its relationship to the right hepatic vein, IVC, diaphragm and adjacent segments, including any boundary crossing. Do not infer a surgical approach or feasibility from the posterosuperior label alone. | VII has no intrinsic outcome score. Its posterosuperior location can affect access and planning, but patient-specific technical risk requires direct vascular, biliary, lesion and liver-reserve assessment. | Brisbane 2000 consensus, right posterior section; PMC4994882, Couinaud segments text (VII superior, VI inferior) and hepatic venous landmarks; PMC4786552, Fig 1. | ✓ |
| VIII | Segment VIII (right anterior, superior) | Superior segment of the right anterior section, generally between the middle- and right-hepatic-vein planes and above the transverse right portal plane. VIII pairs with V in the Brisbane right anterior section. | Report VIII and whether the lesion reaches IV, V, VII, the hepatic veins, IVC, hilum or dome. V with VIII forms the right anterior section, but this grouping does not itself choose resection or ablation. | VIII is a location code rather than a risk category. Central or posterosuperior relationships may influence access and vascular control, but no numeric prognosis follows from VIII itself. | Couinaud 1999, portal and hepatic-vein segmentation; Brisbane 2000 consensus, right anterior section; PMC4994882, Couinaud segments text (VIII superior, V inferior); PMC4786552, Figs 1-2. | ✓ |

### Per-category citations
- **I**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Couinaud 1999, PMID 10805544, portal plus suprahepatic segmentation; Anatomy of Hepatic Resectional Surgery, PMC4994882, Couinaud segments text and Fig 7; Brisbane context in PMC4786552, segment-1 naming rule.
- **II**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · IHPBA Brisbane 2000 consensus, DOI 10.1016/S1365-182X(17)30755-4, second- and third-order divisions; PMC4994882, Couinaud segments and Brisbane terminology; PMC4786552, Figs 1-2.
- **III**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · IHPBA Brisbane 2000 consensus, second-order left lateral section and third-order segment terminology; PMC4994882, Couinaud segments text explaining the original II versus III/IV sectors and Brisbane II/III versus IV sections.
- **IV**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Brisbane 2000 consensus, left medial section and segment nomenclature; PMC4994882, Couinaud segments and Brisbane terminology, including variable IVa/IVb branching; PMC4786552, segment-oriented planning context.
- **IVa**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · PMC4994882, Couinaud segments text and Fig 5: segment IV may be divided into IVA superiorly and IVB inferiorly, with variable branching; Brisbane 2000 consensus for left medial-section terminology.
- **IVb**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · PMC4994882, Couinaud segments text and Fig 5 (IVB inferior to the left portal plane and variable subdivision); Brisbane 2000 consensus, left medial section.
- **V**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Couinaud 1999, portal and hepatic-vein segmentation; Brisbane 2000 consensus, right anterior section; PMC4994882, Couinaud segments text (V inferior, VIII superior); PMC4786552, Figs 1-2.
- **VI**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Brisbane 2000 consensus, right posterior section; PMC4994882, Couinaud segments text (VI inferior, VII superior); PMC4786552, segmental anatomy and resection terminology.
- **VII**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Brisbane 2000 consensus, right posterior section; PMC4994882, Couinaud segments text (VII superior, VI inferior) and hepatic venous landmarks; PMC4786552, Fig 1.
- **VIII**: Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. The Brisbane 2000 Terminology of Liver Anatomy and Resections (2000) — https://doi.org/10.1016/S1365-182X(17)30755-4 · Couinaud 1999, portal and hepatic-vein segmentation; Brisbane 2000 consensus, right anterior section; PMC4994882, Couinaud segments text (VIII superior, V inferior); PMC4786552, Figs 1-2.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2021-11-29 | revised | The Tokyo 2020 consensus added definitions for anatomic segmentectomy and subsegmentectomy while retaining the base segmental anatomy. | confirmed |
| 2000-05-01 | revised | The IHPBA Brisbane consensus standardized liver anatomy and resection terminology around the Couinaud segment map. | confirmed |
| 1957-01-01 | published | Couinaud published the classic segmental liver model in Le foie: etudes anatomiques et chirurgicales. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/couinaud · API JSON: https://radcommons.laudos.ai/api/v1/systems/couinaud · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# LI-RADS — Liver Imaging Reporting and Data System, CT/MRI v2018

> Categorization of liver observations in patients at risk for hepatocellular carcinoma using major imaging features.

**Status:** current · **Organ:** Liver · **Issuing body:** American College of Radiology · **Version:** CT/MRI v2018 · **Year:** 2018

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: matrix
- Modality: CT, MRI
- Primary source: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply only after confirming the high-risk population and adequate multiphase technique. Follow the precedence branches before the major-feature table; LR-TIV indicates malignancy but not necessarily HCC.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| LR-NC | Not categorizable | Not categorizable because omitted or degraded key phases prevent meaningful separation across both likely-benign and likely-malignant diagnostic categories. Do not use LR-NC merely for unusual features or inability to assess ancillary features. | Recommend repeat or alternative diagnostic imaging within 3 months. Report the responsible technical limitation or artifact and whether it is resolvable with the same modality or requires another modality or contrast agent. | Malignancy probability is indeterminate because the examination cannot support a meaningful LI-RADS category; LR-NC is a technical-evaluability result, not a low-risk category. | ACR CT/MRI LI-RADS v2018 Core pp 7 and 14; ACR Diagnostic Categories FAQ-027; ACR Reporting FAQ-076. | ✓ |
| LR-1 | Definitely benign | Definitely benign observation based on unequivocal imaging appearance, such as a simple cyst or another lesion for which imaging establishes benignity. The diagnostic algorithm assigns this branch before the major-feature table. | Return to routine HCC surveillance at the standard 6-month interval for the at-risk population; individual LR-1 observations need not be followed as indeterminate lesions. | The category conveys definite benignity. It does not mean that every benign hepatocellular entity can be assigned LR-1 when imaging cannot establish that certainty. | ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-8 and management p 14; ACR Diagnostic Categories FAQ-023. | ✓ |
| LR-2 | Probably benign | Probably benign observation: imaging favors benignity but does not meet the certainty required for LR-1. Distinctive nodules under 20 mm without major or LR-M features may remain LR-2 unless ancillary features favor malignancy. | Return to routine HCC surveillance in 6 months. Repeat diagnostic imaging within 6 months may be considered when the observation warrants specific reassessment. | The category conveys probable benignity rather than absence of risk; it is below the intermediate-probability LR-3 category in the LI-RADS probability scale. | ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-10 and management p 14; ACR Diagnostic Categories FAQs 037-039. | ✓ |
| LR-3 | Intermediate probability of malignancy | Intermediate probability of malignancy. Diagnostic-table examples include: no APHE with no additional major feature at any size; no APHE with one additional major feature when under 20 mm; nonrim APHE with no additional major feature when under 20 mm; and nonrim APHE under 10 mm regardless of up to one additional major feature. | Repeat or alternative multiphase diagnostic imaging in 3-6 months. Multidisciplinary discussion may be added when the observation or clinical context is complex. | Intermediate probability of malignancy. LR-3 does not exclude non-HCC malignancy and should not be treated as a histologic diagnosis. | ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Diagnostic Categories FAQs 022-023 and 045. | ✓ |
| LR-4 | Probably HCC | Probably HCC. Table pathways include: no APHE with two or more additional major features below 20 mm; no APHE at 20 mm or larger with one or more; nonrim APHE below 10 mm with one or more; nonrim APHE 10-19 mm with enhancing capsule as the only additional major feature; or nonrim APHE at least 20 mm with no additional major feature. | Multidisciplinary discussion for tailored work-up. Options may include biopsy; when neither biopsy nor treatment is planned, use repeat or alternative diagnostic imaging within 3 months. | The category means HCC is probable but not definite. A minority may represent non-HCC malignancy, so LR-4 is not interchangeable with pathology or LR-5. | ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Diagnostic Categories FAQs 022-023 and 045-048. | ✓ |
| LR-5 | Definitely HCC | Definitely HCC within the intended high-risk population. Requires nonrim APHE and diameter at least 10 mm: at 10-19 mm, either nonperipheral washout or threshold growth as the single additional major feature, or at least two additional major features; at 20 mm or larger, at least one additional major feature. An observation under 10 mm cannot be LR-5. | Treat as an imaging diagnosis of HCC and use multidisciplinary discussion for consensus management. Biopsy is not required solely to establish the imaging diagnosis, although clinical circumstances may still lead to tissue sampling. | The category is designed to convey definite HCC in the applicable population. Positive predictive value can be lower with an active extrahepatic hypervascular malignancy, where LR-M and multidisciplinary review may be safer. | ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Application FAQ-005; ACR Diagnostic Categories FAQs 023, 028, and 048. | ✓ |
| LR-M | Probably or definitely malignant, not HCC specific | Probably or definitely malignant but not HCC-specific. Assign before the major-feature table when a targetoid pattern or another feature suggests non-HCC malignancy; the differential includes atypical HCC, intrahepatic cholangiocarcinoma, and combined HCC-cholangiocarcinoma. | Multidisciplinary discussion for tailored work-up, often including biopsy; options may also include alternative or repeat imaging or treatment according to the suspected tumor type and clinical context. | High probability of malignancy, but the category does not exclude HCC and does not establish a specific histology. Its purpose is to flag that management may differ from imaging-definite HCC. | ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-10 and management p 14; ACR Diagnostic Categories FAQs 028-033; ACR Reporting FAQs 072-073. | ✓ |
| LR-TIV | Tumor in vein | Unequivocal enhancing soft tissue within a vein. The category indicates tumor in vein whether or not a parenchymal mass is visible; any contiguous parenchymal observation should also receive its own LI-RADS category. | Multidisciplinary discussion for tailored work-up. Report involved vessels and the most likely etiology when possible; biopsy or biomarker correlation may be used to distinguish HCC, intrahepatic cholangiocarcinoma, combined tumor, or another malignancy. | Tumor in vein indicates malignancy, but it is not automatically HCC. HCC is common, while intrahepatic cholangiocarcinoma, combined HCC-cholangiocarcinoma, and rarely metastases can also invade veins. | ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm p 7, reporting pp 18 and 21, and management p 14; ACR Diagnostic Categories FAQs 034-035; ACR Reporting FAQs 070-071. | ✓ |

### Per-category citations
- **LR-NC**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core pp 7 and 14; ACR Diagnostic Categories FAQ-027; ACR Reporting FAQ-076.
- **LR-1**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-8 and management p 14; ACR Diagnostic Categories FAQ-023.
- **LR-2**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-10 and management p 14; ACR Diagnostic Categories FAQs 037-039.
- **LR-3**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Diagnostic Categories FAQs 022-023 and 045.
- **LR-4**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Diagnostic Categories FAQs 022-023 and 045-048.
- **LR-5**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic table p 8 and management p 14; ACR Application FAQ-005; ACR Diagnostic Categories FAQs 023, 028, and 048.
- **LR-M**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm pp 7-10 and management p 14; ACR Diagnostic Categories FAQs 028-033; ACR Reporting FAQs 072-073.
- **LR-TIV**: Chernyak V, Fowler KJ, Kamaya A, et al.. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients (2018) — https://doi.org/10.1148/radiol.2018181494 · ACR CT/MRI LI-RADS v2018 Core diagnostic algorithm p 7, reporting pp 18 and 21, and management p 14; ACR Diagnostic Categories FAQs 034-035; ACR Reporting FAQs 070-071.

## Cross-references
- _shared boundary_ → [BI-RADS — Breast Imaging Reporting and Data System, 5th edition](https://radcommons.laudos.ai/systems/bi-rads-2013.md) — Shares the ACR Reporting and Data System framework that BI-RADS established.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-23 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-21 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-20 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-19 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-18 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-17 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-16 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-15 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2018-07-01 | revised | LI-RADS CT/MRI v2018 released, updating v2017. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/li-rads-ct-mri-2018 · API JSON: https://radcommons.laudos.ai/api/v1/systems/li-rads-ct-mri-2018 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# LI-RADS TR — LI-RADS Treatment Response

> Assesses response of treated HCC observations after locoregional therapy.

**Status:** current · **Organ:** Liver · **Issuing body:** American College of Radiology · **Version:** v2018 · **Year:** 2018

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Kielar A, Fowler KJ, Lewis S, et al.. LI-RADS Treatment Response algorithm (CT/MRI) (2018) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| Nonviable | LR-TR Nonviable | Treated observation showing no perceived intralesional enhancement, or showing only expected post-treatment enhancement patterns (e.g., a thin uniform peripheral rim of enhancement) for the type of locoregional therapy used and the time elapsed since treatment. This category indicates no imaging evidence of gross (macroscopic) tumor viability, though it does not exclude microscopic tumor on histology. | Per the AASLD/LI-RADS consensus management suggestions cited in the source, a nonviable treated observation is managed with continued routine imaging surveillance; no measurement of viable tumor is reported. | Reflects low perceived probability of macroscopic tumor viability/recurrence. | PMC6920285 (Kierans/Chernyak et al., Insights Imaging 2019, LR-TR pictorial review) 'LR-TR response categories - LR-TR Nonviable'; cross-checked PMC5771991 (Abdom Radiol 2017) 'LI-RADS treatment response algorithm' | ✓ |
| Equivocal | LR-TR Equivocal | Treated observation with enhancement that cannot be confidently categorized as either viable or nonviable because of overlapping post-treatment enhancement features, in the absence of technical or patient-related limitations (i.e., the study is adequate but findings are indeterminate). | Source notes that for an equivocal response the decision to re-treat is weighed against short-interval follow-up imaging, typically after multidisciplinary discussion; if unsure between categories the algorithm directs choosing Equivocal. The viable-tumor size is still reported. | Intermediate / uncertain probability of residual or recurrent viable tumor. | PMC6920285 'LR-TR response categories - LR-TR Equivocal' and 'Pitfalls' / tie-breaking text; PMC5771991 'LI-RADS treatment response algorithm' | ✓ |
| Viable | LR-TR Viable | Treated observation with nodular, mass-like, or thick irregular tissue showing arterial-phase hyperenhancement (APHE), 'washout' appearance, or enhancement similar to the pre-treatment tumor. These features indicate macroscopic viable tumor with high certainty (applies to all locoregional therapies except radiation-based therapy, where intralesional enhancement and washout can persist for months before regressing). | Per the source, the largest single dimension of the enhancing (viable) tumor is measured and reported to guide re-treatment or alternative therapy; reporting the pre- and post-treatment category/size communicates magnitude of response and transplant/downstaging eligibility. | Reflects high perceived probability of residual/recurrent viable tumor. | PMC6920285 'LR-TR response categories - LR-TR Viable' and 'Management recommendations'; PMC5771991 'LI-RADS treatment response algorithm' | ✓ |
| Nonevaluable | LR-TR Nonevaluable | Treated observation in which treatment response cannot be assessed because of image degradation or omission — e.g., inadequate or absent multiphase post-contrast imaging, motion or other technical artifact, or missing pre-treatment comparison. The study quality, not the lesion biology, precludes assigning a viability category. | Per the source algorithm, a nonevaluable observation should be re-imaged after the technical limitation is corrected (repeat or optimized contrast-enhanced CT/MRI) so that a definitive LR-TR category can be assigned; no viable-tumor measurement is reported until evaluable. | No viability probability can be assigned — the category conveys uncertainty due to inadequate technique rather than a level of tumor-viability risk. | PMC6920285 (Kierans/Chernyak et al., Insights Imaging 2019) 'LR-TR response categories - LR-TR Nonevaluable' (treatment response cannot be evaluated due to image degradation/omission); corroborated by PMC5771991 (Mendiratta-Lala et al., Abdom Radiol 2017) 'LI-RADS treatment response algorithm'. | ✓ |

### Per-category citations
- **Nonviable**: Kielar A, Fowler KJ, Lewis S, et al.. LI-RADS Treatment Response algorithm (CT/MRI) (2018) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC6920285 (Kierans/Chernyak et al., Insights Imaging 2019, LR-TR pictorial review) 'LR-TR response categories - LR-TR Nonviable'; cross-checked PMC5771991 (Abdom Radiol 2017) 'LI-RADS treatment response algorithm'
- **Equivocal**: Kielar A, Fowler KJ, Lewis S, et al.. LI-RADS Treatment Response algorithm (CT/MRI) (2018) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC6920285 'LR-TR response categories - LR-TR Equivocal' and 'Pitfalls' / tie-breaking text; PMC5771991 'LI-RADS treatment response algorithm'
- **Viable**: Kielar A, Fowler KJ, Lewis S, et al.. LI-RADS Treatment Response algorithm (CT/MRI) (2018) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC6920285 'LR-TR response categories - LR-TR Viable' and 'Management recommendations'; PMC5771991 'LI-RADS treatment response algorithm'
- **Nonevaluable**: Kielar A, Fowler KJ, Lewis S, et al.. LI-RADS Treatment Response algorithm (CT/MRI) (2018) — https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS · PMC6920285 (Kierans/Chernyak et al., Insights Imaging 2019) 'LR-TR response categories - LR-TR Nonevaluable' (treatment response cannot be evaluated due to image degradation/omission); corroborated by PMC5771991 (Mendiratta-Lala et al., Abdom Radiol 2017) 'LI-RADS treatment response algorithm'.

## Cross-references
- _characterizes_ → [LI-RADS — Liver Imaging Reporting and Data System, CT/MRI v2018](https://radcommons.laudos.ai/systems/li-rads-ct-mri-2018.md) — LI-RADS TR assesses treated observations categorized by diagnostic LI-RADS.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/li-rads-tr · API JSON: https://radcommons.laudos.ai/api/v1/systems/li-rads-tr · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Milan — Classic Milan criteria for liver-transplant selection in hepatocellular carcinoma

> Binary tumor-burden selection boundary: one HCC 5 cm or smaller, or two to three HCCs each 3 cm or smaller, with no macrovascular invasion and no extrahepatic spread. It is not identical to OPTN T2, not automatic transplant eligibility or MELD exception, and not a patient-specific survival estimate; current use must preserve pretreatment and residual viable burden, AFP, liver function, performance status, contraindications and jurisdictional transplant policy.

**Status:** current · **Organ:** Liver · **Issuing body:** Milan group / AASLD / transplant programs · **Version:** 1996 classic criteria; AASLD 2023 care context; OPTN HCC policy effective 2025 reviewed 2026 · **Year:** 1996

## Provenance and currency
- Family: algorithm
- Logic type: flat
- Modality: CT, MRI, Clinical
- Primary source: Mazzaferro V, Regalia E, Doci R, et al.. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis (Milan criteria) (1996) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5218905/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Assign classic Milan from a transparent lesion ledger, then separately reason about diagnosis, treatment response, OPTN policy, transplant eligibility and prognosis. Never use the binary label as an autonomous transplant decision.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| within-milan | Within classic Milan criteria | Within classic Milan requires either one viable HCC measuring 5 cm or smaller, or two to three viable HCCs each measuring 3 cm or smaller, with no macrovascular invasion and no extrahepatic spread. Use a lesion-by-lesion ledger and inclusive boundaries; after locoregional therapy report both presenting burden and current residual viable burden. | Within Milan supports transplant consideration only in an otherwise transplant-eligible patient after multidisciplinary evaluation of liver function, portal hypertension, performance status, resection options, AFP, contraindications and allocation context. It does not itself place the patient on a waiting list, award MELD exception points or choose transplant over resection or ablation. Evaluate OPTN T2 separately when US policy applies. | Within Milan identifies a selected cohort with generally favorable transplant outcomes, not this patient's survival or recurrence probability. AFP and tumor biology, treatment response, wait time, occult microvascular invasion, liver function, donor factors and center practice remain important; do not reuse historical cohort percentages as individualized risk. | Mazzaferro et al. NEJM 1996, DOI 10.1056/NEJM199603143341104, selection criteria; Singal et al. AASLD 2023, DOI 10.1097/HEP.0000000000000466, liver-transplantation section and recommendations 33-36; OPTN Policy 9.5.I.i-ii for separate T2 and AFP gates. | ✓ |
| beyond-milan | Beyond classic Milan criteria | Beyond classic Milan means a solitary viable HCC larger than 5 cm, two or three viable HCCs with any lesion larger than 3 cm, four or more viable HCCs, macrovascular invasion, and/or extrahepatic spread. State the exact reason because size/number excess, vascular invasion and metastasis have different policy and care implications. | Beyond Milan is not one treatment order or permanent futility. Patients otherwise transplant eligible whose excess is tumor size or number, especially those within UNOS downstaging inclusion, may be considered after successful downstaging to within Milan and 3-6 months of observation. Disease outside standard downstaging, macrovascular invasion or extrahepatic spread requires explicit multidisciplinary staging and policy review; US cases outside automatic criteria may require NLRB consideration. | Beyond Milan is a heterogeneous selection state, not a calibrated prognosis. Outcome depends on how the boundary is exceeded, AFP and biology, response and durability after locoregional therapy, liver function, performance status and metastatic or vascular disease; the label alone cannot establish transplant exclusion, recurrence probability or survival. | Singal et al. AASLD 2023, DOI 10.1097/HEP.0000000000000466, downstaging discussion, Figure 12 and recommendation 36; OPTN Policy 9.5.I.iii-iv for initial downstaging geometry, viable T2 response, NLRB routing and AFP rules; classic boundary from Mazzaferro et al. 1996. | ✓ |

### Per-category citations
- **within-milan**: Singal AG, Llovet JM, Yarchoan M, et al.. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10663390/ · Mazzaferro et al. NEJM 1996, DOI 10.1056/NEJM199603143341104, selection criteria; Singal et al. AASLD 2023, DOI 10.1097/HEP.0000000000000466, liver-transplantation section and recommendations 33-36; OPTN Policy 9.5.I.i-ii for separate T2 and AFP gates.
- **beyond-milan**: Singal AG, Llovet JM, Yarchoan M, et al.. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10663390/ · Singal et al. AASLD 2023, DOI 10.1097/HEP.0000000000000466, downstaging discussion, Figure 12 and recommendation 36; OPTN Policy 9.5.I.iii-iv for initial downstaging geometry, viable T2 response, NLRB routing and AFP rules; classic boundary from Mazzaferro et al. 1996.

## Cross-references
- _characterizes_ → [LI-RADS — Liver Imaging Reporting and Data System, CT/MRI v2018](https://radcommons.laudos.ai/systems/li-rads-ct-mri-2018.md) — LI-RADS establishes observation-level diagnostic and treatment-response categories in an eligible population. Milan then aggregates confirmed viable HCC number, size, macrovascular invasion and extrahepatic spread; indeterminate LR observations are not automatically counted as HCC.
- _shared boundary_ → [BCLC — Barcelona Clinic Liver Cancer staging](https://radcommons.laudos.ai/systems/bclc.md) — Classic Milan is a tumor-burden transplant-selection boundary. BCLC separately integrates tumor extent, liver function and performance status to guide treatment; within Milan does not automatically determine BCLC stage or transplant.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2025-07-01 | revised | Current OPTN HCC exception policy aligned terminology further with LI-RADS and retained policy-specific T2, downstaging, viable-lesion and AFP gates. These US allocation rules are related to but not synonymous with classic Milan. | confirmed |
| 2023-05-22 | revised | AASLD current HCC guidance retained Milan as the transplant-selection boundary, distinguished transplant eligibility from listing and allocation, and recommended consideration after successful downstaging with a 3-to-6-month observation period. This did not alter the classic number-and-size criteria. | confirmed |
| 1996-03-14 | published | Milan criteria published by Mazzaferro et al. in the New England Journal of Medicine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/milan-criteria · API JSON: https://radcommons.laudos.ai/api/v1/systems/milan-criteria · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# ARCO — 2019 revised ARCO staging of osteonecrosis of the femoral head

> Per-hip stage I-IV framework for nontraumatic osteonecrosis of the femoral head. A subchondral or necrotic-zone fracture is the decisive stage-II/III boundary; lesion size and location, symptoms, age and patient goals remain separate inputs and must not be inferred from the stage.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Association Research Circulation Osseous · **Version:** 2019 revised staging; 2026 ARCO/AAOS care context · **Year:** 2019

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI, XR, CT
- Primary source: Yoon BH, Mont MA, Koo KH, et al.. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head (2020) — https://pubmed.ncbi.nlm.nih.gov/31866252/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Stage each hip from the highest directly supported structural finding. Fracture is the stage-II/III boundary; lesion size, location, symptoms and treatment choice remain explicit separate inputs.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | 2019 revised ARCO stage I is a hip with normal radiographs but osteonecrosis demonstrated by a band-like low-signal lesion on T1-weighted MRI and/or a positive bone scan. There is no subchondral or necrotic-zone fracture, femoral-head depression or secondary osteoarthritis. Stage each hip independently and do not emit the deleted historical stage 0 for an imaging-negative hip. | MRI is the preferred diagnostic test. For an asymptomatic or symptomatic pre-fracture hip, discuss observation versus joint-preserving intervention using symptoms, lesion size and location, age and patient goals. The 2026 ARCO guideline allows consideration of core decompression and selected augmentation but does not establish one universally superior intervention or authorize a stage-I-only treatment command. | Stage I is structurally pre-fracture, but the stage supplies no calibrated individual probability of collapse. Lesion size and weight-bearing location are major separate determinants, so two stage-I hips can have materially different risk. Record the named size/location method, symptoms, etiology and serial imaging instead of assigning a stage-only percentage. | Yoon et al. J Arthroplasty 2020, DOI 10.1016/j.arth.2019.11.029, 2019 revised ARCO staging table and revision rationale; Cheng et al. JBJS 2026, DOI 10.2106/JBJS.25.01616, Recommendations on diagnostic MRI, asymptomatic stage I-II and core decompression; ARCO update review PMC8216992, 2019 staging and separate size/location systems. | ✓ |
| 2 | Grade 2 | 2019 revised ARCO stage II has radiographic osteonecrosis such as sclerosis, focal osteoporosis or cystic change, but no subchondral or necrotic-zone fracture, no femoral-head flattening or depression and no secondary osteoarthritis. If fracture status is unresolved, especially on radiography alone, retain stage II versus III uncertainty and use CT or appropriate MRI review rather than assuming stage II. | For stage II without fracture, use shared decision-making informed by pain, function, lesion size and location, age, etiology and expected lifespan. Core decompression with or without bone-marrow-cell augmentation and selected vascularized grafting or osteotomy may be considered, but evidence is weak or low and does not support an automatic procedure. CT can be important when an occult fracture would change the stage and counseling. | Stage II remains pre-fracture but is not a uniform collapse-risk group. Extent and location are intentionally outside the 2019 stage and strongly modify risk; the stage paper provides no portable per-stage probability. A reported stage II should therefore include fracture-detection adequacy and a separate lesion-extent descriptor. | Yoon et al. 2020 primary revised staging table, stage II and deleted size/location subclasses; Cheng et al. 2026 guideline, diagnostic CT/MRI for subchondral fracture and stage I-II joint-preservation recommendations; PMC8216992, size/location as major collapse determinants distinct from ARCO stage. | ✓ |
| 3 | Grade 3 | 2019 revised ARCO stage III requires a subchondral or necrotic-zone fracture on radiography or CT, with or without visible collapse. Measure maximum femoral-head depression: IIIA is 2 mm or less, including exactly 2 mm, and IIIB is more than 2 mm. A fracture is sufficient for stage III before flattening; collapse without secondary osteoarthritis remains stage III rather than IV. | After fracture or collapse, compare the smaller and less predictable functional benefit of joint preservation with total hip arthroplasty through shared decision-making, particularly in younger patients. Age, remaining lifespan, depression, lesion size/location, symptoms, function and preferences are required. Stage III does not autonomously select grafting, osteotomy or arthroplasty, and IIIA versus IIIB is not a stand-alone procedure rule. | Stage III demonstrates structural failure and generally carries greater progression and arthroplasty concern than pre-fracture stages, but neither IIIA nor IIIB has a universal individual outcome percentage in the staging system. Depression, extent, location, symptoms and patient factors remain necessary, and serial exams must preserve the date at which fracture or collapse first became visible. | Yoon et al. 2020 primary revised staging table, stage III fracture criterion and 2 mm IIIA/IIIB boundary; Cheng et al. 2026 guideline, stage-III joint-preservation versus total-hip-arthroplasty counseling and age, lesion-size and patient-value context. | ✓ |
| 4 | Grade 4 | 2019 revised ARCO stage IV is secondary osteoarthritis on radiography, with joint-space narrowing, acetabular change and/or joint destruction after femoral-head osteonecrosis and collapse. Collapse alone is insufficient; verify an osteoarthritic joint or acetabular feature before moving a hip from stage III to IV. | Secondary osteoarthritis commonly makes total hip arthroplasty an important option, but management still depends on pain, disability, age, comorbidity, prior preservation procedures and patient goals. The stage must not be converted into an automatic arthroplasty order, and the contralateral hip requires its own independent stage and care plan. | Stage IV represents the most advanced structural category and established secondary joint degeneration, not a calibrated probability of pain, disability, surgical candidacy or implant outcome. Report function, symptoms, joint destruction, bone stock and patient context rather than treating the numeral as an individual prognosis. | Yoon et al. 2020 primary revised staging table, stage-IV joint-space, acetabular and joint-destruction criteria; Cheng et al. 2026 evidence-based guideline, treatment framework and shared-decision boundary for advanced nontraumatic osteonecrosis. | ✓ |

### Per-category citations
- **1**: Yoon BH, Mont MA, Koo KH, et al.. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head (2020) — https://pubmed.ncbi.nlm.nih.gov/31866252/ · Yoon et al. J Arthroplasty 2020, DOI 10.1016/j.arth.2019.11.029, 2019 revised ARCO staging table and revision rationale; Cheng et al. JBJS 2026, DOI 10.2106/JBJS.25.01616, Recommendations on diagnostic MRI, asymptomatic stage I-II and core decompression; ARCO update review PMC8216992, 2019 staging and separate size/location systems.
- **2**: Yoon BH, Mont MA, Koo KH, et al.. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head (2020) — https://pubmed.ncbi.nlm.nih.gov/31866252/ · Yoon et al. 2020 primary revised staging table, stage II and deleted size/location subclasses; Cheng et al. 2026 guideline, diagnostic CT/MRI for subchondral fracture and stage I-II joint-preservation recommendations; PMC8216992, size/location as major collapse determinants distinct from ARCO stage.
- **3**: Yoon BH, Mont MA, Koo KH, et al.. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head (2020) — https://pubmed.ncbi.nlm.nih.gov/31866252/ · Yoon et al. 2020 primary revised staging table, stage III fracture criterion and 2 mm IIIA/IIIB boundary; Cheng et al. 2026 guideline, stage-III joint-preservation versus total-hip-arthroplasty counseling and age, lesion-size and patient-value context.
- **4**: Yoon BH, Mont MA, Koo KH, et al.. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head (2020) — https://pubmed.ncbi.nlm.nih.gov/31866252/ · Yoon et al. 2020 primary revised staging table, stage-IV joint-space, acetabular and joint-destruction criteria; Cheng et al. 2026 evidence-based guideline, treatment framework and shared-decision boundary for advanced nontraumatic osteonecrosis.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-01-20 | revised | ARCO adopted an international evidence-based clinical practice guideline for nontraumatic femoral-head osteonecrosis. It supplies current imaging and care context without changing the 2019 stage codes. | confirmed |
| 2019-12-24 | revised | ARCO published its 2019 revised staging: historical stage 0 was deleted, stage III was split at 2 mm of femoral-head depression, and prior size/location subclasses were left outside the I-IV stage. | confirmed |
| 2019-06-01 | revised | ARCO classification revised (2019). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/arco · API JSON: https://radcommons.laudos.ai/api/v1/systems/arco · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Bone-RADS — Bone Reporting and Data System

> Management categories for incidentally detected solitary bone lesions on CT and MRI.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** American College of Radiology · **Version:** 2022 · **Year:** 2022

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Chang CY, Garner HW, Ahlawat S, et al.. Bone Reporting and Data System (Bone-RADS) for incidentally detected solitary bone lesions (2022) — https://doi.org/10.1007/s00256-022-04022-8
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Bone-RADS 1, leave alone | Lesion judged clearly benign on CT or MRI - for example one with a definitive benign diagnosis (such as enostosis, non-ossifying fibroma, fibrous dysplasia, enchondroma, subchondral cyst, or hemangioma), confirmed internal macroscopic fat, or fat-matching/cortical-bone-matching signal - so that no additional workup is needed. | Leave alone: no further imaging, follow-up, or tissue sampling required. | — | PMC9283187 (Chang CY et al., Skeletal Radiol 2022, Bone-RADS), 'Management options: Bone-RADS' section and Table; lucent / sclerotic-mixed / MRI algorithm sections (e.g., Case 1, 2, 9, 10) | ✓ |
| 2 | Bone-RADS 2, follow up or further imaging | Indeterminate lesion for which characterization is incomplete on the current study and additional diagnostic information from a different imaging modality is needed (e.g., FDG-PET, bone scan, MRI, CT, chemical-shift or contrast-enhanced sequences, or radiographs). | Perform a different imaging modality to further characterize the lesion. | — | PMC9283187 'Management options: Bone-RADS' section and Table; indeterminate-lesion branches of the CT lucent, CT sclerotic/mixed, and MRI algorithms (e.g., Case 8 red marrow assigned Bone-RADS2) | ✓ |
| 3 | Bone-RADS 3, biopsy or oncology referral | Indeterminate lesion judged appropriate for surveillance with the same imaging modality to detect interval growth or development of worrisome features such as cortical involvement. | Perform follow-up imaging; the suggested schedule is repeat imaging at 6, 6, and 12 month intervals for a total of 2 years. | — | PMC9283187 'Management options: Bone-RADS' section and Table (follow-up at 6, 6, 12 months over 2 years) | ✓ |

### Per-category citations
- **1**: Chang CY, Garner HW, Ahlawat S, et al.. Bone Reporting and Data System (Bone-RADS) for incidentally detected solitary bone lesions (2022) — https://doi.org/10.1007/s00256-022-04022-8 · PMC9283187 (Chang CY et al., Skeletal Radiol 2022, Bone-RADS), 'Management options: Bone-RADS' section and Table; lucent / sclerotic-mixed / MRI algorithm sections (e.g., Case 1, 2, 9, 10)
- **2**: Chang CY, Garner HW, Ahlawat S, et al.. Bone Reporting and Data System (Bone-RADS) for incidentally detected solitary bone lesions (2022) — https://doi.org/10.1007/s00256-022-04022-8 · PMC9283187 'Management options: Bone-RADS' section and Table; indeterminate-lesion branches of the CT lucent, CT sclerotic/mixed, and MRI algorithms (e.g., Case 8 red marrow assigned Bone-RADS2)
- **3**: Chang CY, Garner HW, Ahlawat S, et al.. Bone Reporting and Data System (Bone-RADS) for incidentally detected solitary bone lesions (2022) — https://doi.org/10.1007/s00256-022-04022-8 · PMC9283187 'Management options: Bone-RADS' section and Table (follow-up at 6, 6, 12 months over 2 years)

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2022-01-01 | published | Bone-RADS published in Skeletal Radiology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bone-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/bone-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Ficat — Ficat classification of avascular necrosis of the femoral head

> Stages osteonecrosis of the femoral head.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1985 · **Year:** 1985

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, MRI
- Primary source: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0 | Preclinical/silent hip: radiographs normal (inconspicuous) and the patient is asymptomatic; diagnosis suspected only by other means (e.g. MRI, opposite-hip disease). | Pre-collapse stage: non-operative/observation (e.g. bisphosphonates) and joint-preserving options; close monitoring given the risk of progression to symptoms or collapse. | Asymptomatic early lesions carry substantial risk of progression: about 59% of asymptomatic lesions progress to symptoms or collapse. | PMC2323428 Table 1 (criteria); NBK537007 (non-operative/joint-preserving for early stages; 59% of asymptomatic lesions progress). | ✓ |
| I | Grade I | Symptomatic hip with radiographs still normal or showing only minor changes (e.g. slight patchy osteoporosis); femoral head shape preserved. | Pre-collapse: joint-preserving surgery, particularly core decompression (most effective in early disease with small weight-bearing involvement), with/without bone grafting or biologic adjuncts; non-operative measures may be used. | Pre-collapse but progressive; core decompression failed to prevent progression in roughly 90% of treated hips, reflecting the high rate of eventual collapse. | PMC2323428 Table 1 (criteria); NBK537007 (core decompression for early stages; ~90% core-decompression failure). | ✓ |
| II | Grade II | Radiographic changes without overall head collapse: diffuse or focal osteoporosis, sclerosis, and cysts (Ficat IIA), progressing to a subchondral fracture (crescent sign) with segmental flattening (Ficat IIB); joint space preserved. | Still considered pre-/peri-collapse: joint-preserving core decompression (+/- grafting) for lesions before frank collapse, most effective when the lesion is small and limited to a small part of the weight-bearing surface. | Once the crescent sign / subchondral fracture appears, progression to collapse is common and joint-preserving procedures are less likely to succeed. | PMC2323428 Table 1 (criteria, incl. crescent sign); NBK537007 (joint-preserving most effective in early stages/small lesions). | ✓ |
| III | Grade III | Broken/disrupted contour of the femoral head with bone sequestrum (true segmental collapse) while the joint space remains normal/preserved. | Post-collapse: total hip arthroplasty is indicated, especially for irreversible etiology, patients over 40, large lesions, or advanced collapse; younger patients with advanced collapse also move toward arthroplasty. | Segmental collapse has occurred; the joint is no longer salvageable by joint-preserving surgery and degenerative end-stage disease typically follows. | PMC2323428 Table 1 (criteria); NBK537007 (total hip arthroplasty indicated for advanced collapse / age >40 / large lesions). | ✓ |
| IV | Grade IV | End stage: flattened femoral head contour, joint-space narrowing/collapse, and secondary osteoarthritic (degenerative) changes of the joint. | Post-collapse end stage: total hip arthroplasty (joint replacement) is the definitive treatment. | Irreversible end-stage osteoarthritic destruction of the hip; joint-preserving options no longer applicable. | PMC2323428 Table 1 (criteria); NBK537007 (total hip arthroplasty for advanced/end-stage disease). | ✓ |

### Per-category citations
- **0**: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis · PMC2323428 Table 1 (criteria); NBK537007 (non-operative/joint-preserving for early stages; 59% of asymptomatic lesions progress).
- **I**: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis · PMC2323428 Table 1 (criteria); NBK537007 (core decompression for early stages; ~90% core-decompression failure).
- **II**: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis · PMC2323428 Table 1 (criteria, incl. crescent sign); NBK537007 (joint-preserving most effective in early stages/small lesions).
- **III**: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis · PMC2323428 Table 1 (criteria); NBK537007 (total hip arthroplasty indicated for advanced collapse / age >40 / large lesions).
- **IV**: Ficat RP. Idiopathic bone necrosis of the femoral head (Ficat) (1985) — https://en.wikipedia.org/wiki/Avascular_necrosis · PMC2323428 Table 1 (criteria); NBK537007 (total hip arthroplasty for advanced/end-stage disease).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/ficat · API JSON: https://radcommons.laudos.ai/api/v1/systems/ficat · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Frykman — Frykman classification of distal radius fractures

> Two-axis morphology label based on radiocarpal and distal-radioulnar joint involvement plus an associated distal-ulna or ulnar-styloid fracture; type numbers are not an ordinal severity or treatment scale.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Frykman / historical orthopedic classification · **Version:** 1967 · **Year:** 1967

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return the two observed axes with the Roman type. The scheme does not encode displacement, comminution, stability, treatment, or calibrated prognosis, and its limited reliability must remain visible to downstream agents.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, neither joint involved, no associated ulna fracture | Distal radius fracture with no extension into either the radiocarpal joint or the distal radioulnar joint, and without an associated distal-ulna or ulnar-styloid fracture. | Use Type I only as the two-axis morphology label. Separately report displacement, shortening, angulation, comminution, stability, soft-tissue and neurovascular findings, and patient factors before any treatment decision. | Type I is not synonymous with stable or low risk. Plain radiographs can underestimate articular extension, and Frykman type does not provide a calibrated prognosis or treatment-failure probability. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type I extra-articular), Frykman Results and Tables 4-5 (limited reliability); Andersen et al. 1996, PMID 8842946, abstract (classification alone should not direct treatment). | ✓ |
| II | Type II, neither joint involved, associated ulna fracture | Distal radius fracture with no extension into either the radiocarpal or distal radioulnar joint, with an associated distal-ulna or ulnar-styloid fracture. The associated ulna finding changes the odd Type I to even Type II. | Describe the associated ulna or styloid fracture and assess DRUJ congruity and stability separately. Type II does not specify displacement, instability, fixation need, or the clinical significance of the ulnar component. | The even-number modifier does not supply an event probability or automatically increase severity. Prognosis depends on morphology and clinical variables that Frykman does not encode. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type II extra-articular with ulnar fracture); Frykman 1967, PMID 4175195; Andersen et al. 1996, PMID 8842946, reliability and standalone-use limitation. | ✓ |
| III | Type III, radiocarpal joint only, no associated ulna fracture | Distal radius fracture extending into the radiocarpal joint but not the distal radioulnar joint, without an associated distal-ulna or ulnar-styloid fracture. | Report the radiocarpal articular step-off or gap, displacement and comminution separately and verify the sigmoid notch. Type III identifies a joint surface but does not choose operative versus nonoperative care. | Radiocarpal involvement is morphologically important, but Type III is not a calibrated arthritis, instability, functional-outcome, or surgical-benefit score. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type III intra-articular into radiocarpal joint) and reliability Results; Andersen et al. 1996, PMID 8842946. | ✓ |
| IV | Type IV, radiocarpal joint only, associated ulna fracture | Distal radius fracture extending into the radiocarpal joint but not the distal radioulnar joint, with an associated distal-ulna or ulnar-styloid fracture. The ulna component changes III to IV. | Characterize radiocarpal congruity, displacement, comminution and the ulna or styloid injury independently. The Type IV label does not establish DRUJ instability or prescribe fixation of either bone. | Type IV combines radiocarpal and ulna morphology without quantifying prognosis. The numeral must not be interpreted as a validated severity rank or patient-specific risk estimate. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type IV radiocarpal involvement with ulnar fracture), Tables 4-5; Frykman 1967, PMID 4175195. | ✓ |
| V | Type V, distal radioulnar joint only, no associated ulna fracture | Distal radius fracture extending into the distal radioulnar joint at the sigmoid notch but not the radiocarpal joint, without an associated distal-ulna or ulnar-styloid fracture. | State sigmoid-notch involvement and assess DRUJ congruity and stability directly; also report displacement and any occult radiocarpal extension. Type V is descriptive and does not determine reduction or fixation strategy. | DRUJ-surface involvement does not yield a numeric instability or functional-outcome probability. The limited reliability of Frykman assignment should remain visible when the sigmoid notch is equivocal. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type V intra-articular into radioulnar joint) and Frykman reliability Results; Andersen et al. 1996, PMID 8842946. | ✓ |
| VI | Type VI, distal radioulnar joint only, associated ulna fracture | Distal radius fracture extending into the distal radioulnar joint but not the radiocarpal joint, with an associated distal-ulna or ulnar-styloid fracture. The ulna component changes V to VI. | Describe the sigmoid-notch extension, DRUJ congruity and stability, and the associated ulna injury separately. Type VI does not state displacement, instability, urgency, or whether an ulnar fragment requires treatment. | Type VI is a morphology combination without a calibrated complication or outcome probability. Even numbering denotes the ulna axis, not a validated increase in severity. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VI radioulnar involvement with ulnar fracture), Tables 4-5; Frykman 1967, PMID 4175195. | ✓ |
| VII | Type VII, both joints involved, no associated ulna fracture | Distal radius fracture extending into both the radiocarpal and distal radioulnar joints, without an associated distal-ulna or ulnar-styloid fracture. Joint involvement alone does not require comminution. | Characterize both articular surfaces, step-off or gap, displacement, comminution, DRUJ congruity and stability, and soft-tissue injury. Type VII does not prescribe surgery or a specific construct. | Both joints are involved, but VII is not defined as 'most fragmented' and is not a numeric severity or prognostic category. Outcome depends on features outside the Frykman axes. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VII radiocarpal plus radioulnar joints) and Results; original Frykman citation PMID 4175195; Andersen et al. 1996, PMID 8842946. | ✓ |
| VIII | Type VIII, both joints involved, associated ulna fracture | Distal radius fracture extending into both the radiocarpal and distal radioulnar joints, with an associated distal-ulna or ulnar-styloid fracture. The ulna component changes VII to VIII; comminution is not part of the definition. | Report both articular surfaces and the associated ulna injury, plus displacement, comminution, alignment, DRUJ stability and soft tissues. Type VIII alone does not mandate surgery or define the operative approach. | VIII is the even member of the both-joints pair, not an automatic 'most severe' designation. Frykman supplies no calibrated prognosis, and study agreement remained limited even with CT. | Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VIII both joints with ulnar fracture), Tables 4-5 and Frykman Results; Andersen et al. 1996, PMID 8842946. | ✓ |

### Per-category citations
- **I**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type I extra-articular), Frykman Results and Tables 4-5 (limited reliability); Andersen et al. 1996, PMID 8842946, abstract (classification alone should not direct treatment).
- **II**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type II extra-articular with ulnar fracture); Frykman 1967, PMID 4175195; Andersen et al. 1996, PMID 8842946, reliability and standalone-use limitation.
- **III**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type III intra-articular into radiocarpal joint) and reliability Results; Andersen et al. 1996, PMID 8842946.
- **IV**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type IV radiocarpal involvement with ulnar fracture), Tables 4-5; Frykman 1967, PMID 4175195.
- **V**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type V intra-articular into radioulnar joint) and Frykman reliability Results; Andersen et al. 1996, PMID 8842946.
- **VI**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VI radioulnar involvement with ulnar fracture), Tables 4-5; Frykman 1967, PMID 4175195.
- **VII**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VII radiocarpal plus radioulnar joints) and Results; original Frykman citation PMID 4175195; Andersen et al. 1996, PMID 8842946.
- **VIII**: Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function (1967) — https://doi.org/10.3109/ort.1967.38.suppl-108.01 · Kleinlugtenbelt et al. 2017, PMC5694815, Table 3 (Type VIII both joints with ulnar fracture), Tables 4-5 and Frykman Results; Andersen et al. 1996, PMID 8842946.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1967-01-01 | published | Frykman published the eight-type distal-radius fracture classification in Acta Orthopaedica Scandinavica Supplementum 108. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/frykman · API JSON: https://radcommons.laudos.ai/api/v1/systems/frykman · Agent index: https://radcommons.laudos.ai/llms.txt

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# Garden — Garden classification of femoral neck fractures

> Classifies intracapsular femoral neck fractures by displacement.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1961 · **Year:** 1961

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Garden RS. Low-angle fixation in fractures of the femoral neck (Garden) (1961) — https://en.wikipedia.org/wiki/Garden_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, incomplete or valgus impacted | Incomplete femoral neck fracture, impacted in valgus and effectively stable (trabeculae not fully disrupted). | Undisplaced fracture: typically internal fixation with screws to preserve the native femoral head. | Undisplaced (Garden I-II) fractures carry low avascular-necrosis risk: pooled AVN ~4.7% (95% CI 3.4-6.0%); per-stage Garden I pooled AVN ~13.6% (95% CI 0-28.4%, wide due to few cases). | Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 (systematic review/meta-analysis of AVN after femoral neck fracture stabilization), pooled rates by displacement and by Garden stage. | ✓ |
| II | Type II, complete non-displaced | Complete fracture but non-displaced; the trabecular lines remain in alignment across the fracture. | Undisplaced fracture: typically internal fixation with screws to preserve the native femoral head. | Undisplaced (Garden I-II) fractures: pooled AVN ~4.7% (95% CI 3.4-6.0%); per-stage Garden II pooled AVN ~12.2% (95% CI 0-26.2%). | Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN by displacement (undisplaced 4.7%) and per stage (Garden II 12.2%). | ✓ |
| III | Type III, complete partially displaced | Complete fracture with partial displacement, in varus, with disruption/malalignment of the trabeculae. | Displaced fracture: usually arthroplasty (prosthetic replacement); younger patients may attempt screw fixation first, proceeding to arthroplasty if it fails. | Displaced (Garden III-IV) fractures more often disrupt the femoral-head blood supply: pooled AVN ~20.7% (95% CI 12.8-28.5%), significantly higher than undisplaced; per-stage Garden III pooled AVN ~17.0% (95% CI 6.4-27.6%). | Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN displaced 20.7% and Garden III 17.0%. | ✓ |
| IV | Type IV, complete fully displaced | Complete fracture with full displacement and no contact between the fracture fragments. | Displaced fracture: usually arthroplasty (prosthetic replacement); younger patients may attempt screw fixation first, proceeding to arthroplasty if it fails. | Displaced (Garden III-IV) fractures: pooled AVN ~20.7% (95% CI 12.8-28.5%); per-stage Garden IV shows the numerically highest AVN, pooled ~32.8% (95% CI 11.8-53.8%). | Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN displaced 20.7% and Garden IV 32.8%. | ✓ |

### Per-category citations
- **I**: Garden RS. Low-angle fixation in fractures of the femoral neck (Garden) (1961) — https://en.wikipedia.org/wiki/Garden_classification · Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 (systematic review/meta-analysis of AVN after femoral neck fracture stabilization), pooled rates by displacement and by Garden stage.
- **II**: Garden RS. Low-angle fixation in fractures of the femoral neck (Garden) (1961) — https://en.wikipedia.org/wiki/Garden_classification · Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN by displacement (undisplaced 4.7%) and per stage (Garden II 12.2%).
- **III**: Garden RS. Low-angle fixation in fractures of the femoral neck (Garden) (1961) — https://en.wikipedia.org/wiki/Garden_classification · Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN displaced 20.7% and Garden III 17.0%.
- **IV**: Garden RS. Low-angle fixation in fractures of the femoral neck (Garden) (1961) — https://en.wikipedia.org/wiki/Garden_classification · Criteria/management: Wikipedia 'Garden classification', classification table and Clinical Relevance section. AVN risk: PMC9408780 meta-analysis, pooled AVN displaced 20.7% and Garden IV 32.8%.

## Cross-references
- _shared boundary_ → [Pauwels — Pauwels classification of femoral neck fractures](https://radcommons.laudos.ai/systems/pauwels.md) — Garden grades femoral neck fracture displacement; Pauwels grades the fracture-line angle.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/garden · API JSON: https://radcommons.laudos.ai/api/v1/systems/garden · Agent index: https://radcommons.laudos.ai/llms.txt

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# Gartland — Gartland classification of supracondylar humerus fractures

> Classifies pediatric supracondylar humeral fractures by displacement.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1959 · **Year:** 1959

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Gartland JJ. Management of supracondylar fractures of the humerus (Gartland) (1959) — https://en.wikipedia.org/wiki/Gartland_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Non-displaced (or minimally displaced) supracondylar humerus fracture with an intact, well-aligned anterior humeral line. | Nonoperative: immobilization in a long-arm cast for about 3-4 weeks, with a radiographic check at roughly 1 week to confirm maintained alignment. | Stable, lowest-risk type; favorable outcome and low rate of neurovascular complication. | PMC4294919 (Alton et al., 'Classifications In Brief: The Gartland Classification of Supracondylar Humerus Fractures', Clin Orthop Relat Res 2015), Treatment section, Type I. | ✓ |
| II | Type II | Displaced/angulated fracture with the posterior cortex still intact (hinge preserved). IIA = angulation only; IIB = angulation with rotational (and/or translational) malalignment. | IIA: closed reduction with casting or percutaneous pinning. IIB: closed reduction and percutaneous pinning to correct and hold coronal/rotational malalignment. | Intermediate; IIB carries greater instability and higher malreduction/malalignment risk than IIA. | PMC4294919 Treatment section, Type IIA and IIB. | ✓ |
| III | Type III | Completely displaced fracture with loss of cortical contact (residual periosteal hinge may persist). IIIA = posteromedial displacement (intact medial hinge); IIIB = posterolateral displacement (intact lateral hinge). | Operative: closed reduction and percutaneous pinning, with open reduction if an acceptable closed reduction cannot be achieved. | Unstable, higher-risk type; associated with the greatest rates of neurologic and vascular injury (vascular injury occurs almost exclusively in extension type III or higher). | PMC4294919 Purpose and Treatment sections, Type III. | ✓ |
| IV | Type IV | Periosteal disruption with multidirectional instability — unstable in both flexion and extension; often identified intraoperatively under fluoroscopy (added by Leitch). | Operative: closed reduction and percutaneous pinning, with possible open reduction and internal fixation if reduction is unstable. | Most unstable pattern; complication risk comparable to or exceeding type III. | PMC4294919 Treatment section, Type IV (multiplanar instability). | ✓ |

### Per-category citations
- **I**: Gartland JJ. Management of supracondylar fractures of the humerus (Gartland) (1959) — https://en.wikipedia.org/wiki/Gartland_classification · PMC4294919 (Alton et al., 'Classifications In Brief: The Gartland Classification of Supracondylar Humerus Fractures', Clin Orthop Relat Res 2015), Treatment section, Type I.
- **II**: Gartland JJ. Management of supracondylar fractures of the humerus (Gartland) (1959) — https://en.wikipedia.org/wiki/Gartland_classification · PMC4294919 Treatment section, Type IIA and IIB.
- **III**: Gartland JJ. Management of supracondylar fractures of the humerus (Gartland) (1959) — https://en.wikipedia.org/wiki/Gartland_classification · PMC4294919 Purpose and Treatment sections, Type III.
- **IV**: Gartland JJ. Management of supracondylar fractures of the humerus (Gartland) (1959) — https://en.wikipedia.org/wiki/Gartland_classification · PMC4294919 Treatment section, Type IV (multiplanar instability).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/gartland · API JSON: https://radcommons.laudos.ai/api/v1/systems/gartland · Agent index: https://radcommons.laudos.ai/llms.txt

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# Gustilo-Anderson — Gustilo-Anderson classification of open fractures

> Grades open (compound) fractures by wound size, soft-tissue injury, contamination, and vascular status to guide antibiotics and predict infection.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Gustilo & Anderson · **Version:** 1984 (Gustilo-Mendoza-Williams) · **Year:** 1976

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Low-energy open fracture with a clean wound under 1 cm and minimal soft-tissue damage. | Gram-positive coverage (e.g. cefazolin or cefuroxime) plus irrigation and debridement. | — | StatPearls 'Open Fracture Management' (NBK448083), classification/wound-examination text: type I = low energy, wound <1 cm, minimal soft-tissue damage; gram-positive antibiotic coverage. | ✓ |
| II | Type II | Low-to-moderate energy open fracture with a wound greater than 1 cm and moderate soft-tissue and muscle damage. | Gram-positive antibiotic coverage, as for type I, with irrigation and debridement. | — | StatPearls NBK448083, classification text: type II = low-to-moderate energy, wound >1 cm, moderate soft-tissue/muscle damage; gram-positive coverage. | ✓ |
| IIIA | Type IIIA | High-energy open fracture with a wound usually greater than 10 cm or severe crushing soft-tissue damage, but with adequate soft-tissue coverage of the exposed bone. | Add gram-negative coverage (e.g. an aminoglycoside such as gentamicin) to gram-positive coverage; high-dose penicillin if fecal/clostridial contamination is suspected. | — | StatPearls NBK448083: type III = high-velocity, wounds >10 cm; IIIA severe crushing soft-tissue damage; type III antibiotics add gram-negative (aminoglycoside) and penicillin for contamination. | ✓ |
| IIIB | Type IIIB | High-energy open fracture with significant loss of soft-tissue coverage and periosteal stripping, leaving exposed bone that requires a soft-tissue flap for coverage. | Gram-positive plus gram-negative coverage with irrigation/debridement; soft-tissue flap reconstruction for coverage. | — | StatPearls NBK448083: IIIB = significant loss of tissue coverage requiring a flap; type III combined gram-positive and gram-negative antibiotic regimen. | ✓ |
| IIIC | Type IIIC | Open fracture with an associated arterial injury requiring repair, regardless of wound size. | Gram-positive plus gram-negative coverage and urgent vascular repair. | By definition involves an arterial injury requiring repair, carrying the greatest limb-loss/amputation risk among the grades. | StatPearls NBK448083: IIIC = significant soft-tissue injury with vascular injury requiring repair; type III antibiotic regimen. | ✓ |

### Per-category citations
- **I**: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/ · StatPearls 'Open Fracture Management' (NBK448083), classification/wound-examination text: type I = low energy, wound <1 cm, minimal soft-tissue damage; gram-positive antibiotic coverage.
- **II**: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/ · StatPearls NBK448083, classification text: type II = low-to-moderate energy, wound >1 cm, moderate soft-tissue/muscle damage; gram-positive coverage.
- **IIIA**: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/ · StatPearls NBK448083: type III = high-velocity, wounds >10 cm; IIIA severe crushing soft-tissue damage; type III antibiotics add gram-negative (aminoglycoside) and penicillin for contamination.
- **IIIB**: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/ · StatPearls NBK448083: IIIB = significant loss of tissue coverage requiring a flap; type III combined gram-positive and gram-negative antibiotic regimen.
- **IIIC**: Sop JL, Sop A. Open Fracture Management (StatPearls) (2023) — https://www.ncbi.nlm.nih.gov/books/NBK448083/ · StatPearls NBK448083: IIIC = significant soft-tissue injury with vascular injury requiring repair; type III antibiotic regimen.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1984-01-01 | revised | Type III subdivided into IIIA, IIIB, and IIIC (Gustilo, Mendoza, Williams). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/gustilo-anderson · API JSON: https://radcommons.laudos.ai/api/v1/systems/gustilo-anderson · Agent index: https://radcommons.laudos.ai/llms.txt

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# Hawkins — Hawkins classification of talar neck fractures

> Classifies talar neck fractures by associated joint dislocation, predicting avascular necrosis risk.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Hawkins / Canale-Kelly · **Version:** 1970 / 1978 (Canale-Kelly) · **Year:** 1970

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures (2015) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4523513/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, nondisplaced | Minimally displaced talar neck fracture line entering the subtalar joint between the middle and posterior facets, with the talus remaining in anatomic position (no subtalar or ankle dislocation). | Nondisplaced pattern; the preserved vascular supply allows the lowest-risk treatment of the four types. | Lowest osteonecrosis risk: no cases of avascular necrosis (0%) in Hawkins' original series. | Alton, Patton, Gee, 'Classifications in Brief: The Hawkins Classification for Talus Fractures', Clin Orthop Relat Res 2015 (PMC4523513), type descriptions and AVN-rate text: type I no AVN in original series. | ✓ |
| II | Type II, subtalar subluxation/dislocation | Vertical, displaced talar neck fracture with the subtalar joint subluxated or dislocated, but the talus remaining reduced within the ankle (tibiotalar) mortise. | Displaced; warrants reduction and fixation to restore alignment and minimize osteonecrosis risk. | Avascular necrosis in about 42% (10 of 24) in Hawkins' original series; roughly 18% in a modern validation study (Halvorson et al., 2013). | PMC4523513, type II description and AVN rates (42% Hawkins original; 18.4% Halvorson validation). | ✓ |
| III | Type III, subtalar and ankle dislocation | Displaced talar neck fracture as in type II with the addition of dislocation of the ankle (tibiotalar) joint, so the body is dislocated from both the subtalar and ankle joints. | Highly displaced; urgent reduction and operative fixation, with the highest osteonecrosis risk to counsel. | Avascular necrosis in about 91% (20 of 22) in Hawkins' original series; roughly 45% in the modern validation study. | PMC4523513, type III description and AVN rates (91% Hawkins original; 44.7% Halvorson validation). | ✓ |
| IV | Type IV, plus talonavicular dislocation | Type added by Canale and Kelly: talar neck fracture with dislocation of the body from the ankle or subtalar joint plus additional dislocation or subluxation of the talar head from the talonavicular joint. | Most severe displacement; operative reduction and fixation of all involved joints. | Avascular necrosis in about 52% (37 of 71) in Canale and Kelly's series; roughly 12% in the modern validation study. | PMC4523513, type IV (Canale-Kelly addition) description and AVN rates (52% Canale-Kelly; 12.1% Halvorson validation). | ✓ |

### Per-category citations
- **I**: Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures (2015) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4523513/ · Alton, Patton, Gee, 'Classifications in Brief: The Hawkins Classification for Talus Fractures', Clin Orthop Relat Res 2015 (PMC4523513), type descriptions and AVN-rate text: type I no AVN in original series.
- **II**: Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures (2015) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4523513/ · PMC4523513, type II description and AVN rates (42% Hawkins original; 18.4% Halvorson validation).
- **III**: Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures (2015) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4523513/ · PMC4523513, type III description and AVN rates (91% Hawkins original; 44.7% Halvorson validation).
- **IV**: Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures (2015) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4523513/ · PMC4523513, type IV (Canale-Kelly addition) description and AVN rates (52% Canale-Kelly; 12.1% Halvorson validation).

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1978-01-01 | revised | Type IV added by Canale and Kelly. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/hawkins-talus · API JSON: https://radcommons.laudos.ai/api/v1/systems/hawkins-talus · Agent index: https://radcommons.laudos.ai/llms.txt

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# Judet-Letournel — Judet-Letournel classification of acetabular fractures

> Per-hemipelvis acetabular fracture classification into five elementary and five associated patterns using column, wall and transverse-component anatomy on pelvic radiographs and CT; the pattern supports approach planning but does not encode hip stability or operative indication by itself.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Judet, Judet & Letournel · **Version:** 1964 / 1980 ten-pattern refinement · **Year:** 1964

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction (1964) — https://pubmed.ncbi.nlm.nih.gov/14239854/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Trace the entire fracture through the columns, walls, transverse component and stable posterior ilium. Return uncertainty when attachment or extension is unresolved, and keep pattern classification separate from stability, prognosis and treatment selection.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| ant-wall | Anterior wall (elementary) | Elementary anterior-wall fracture: an independent anterior acetabular rim or wall fragment is present without complete separation of the anterior column. Confirm the wall fragment in more than one plane and account for the remaining column continuity. | The pattern identifies anterior articular exposure as the planning problem; an anterior approach is a historical option when fixation is indicated. Operative need and the exact approach still depend on displacement, congruence, dome involvement, stability and patient factors. | The label does not quantify outcome or hip stability. Prognosis depends more directly on articular displacement and reduction, marginal impaction, comminution, femoral-head injury, intra-articular fragments and age than on the wall label alone. | Alton and Gee 2014, History/Purpose and Fig. 1 list anterior wall among the five elementary patterns; Purpose and Limitations address approach planning, stability and outcome modifiers. Gansslen et al. 2024, AP wall-line and Judet-view analysis. | ✓ |
| post-wall | Posterior wall (elementary) | Elementary posterior-wall fracture: an independent posterior acetabular wall fragment is present while the posterior column remains continuous. Distinguish a true isolated wall fragment from posterior-wall involvement within an associated pattern. | A posterior exposure is the classic approach family when fixation is required, but the code alone cannot decide surgery. Report fragment size, displacement, marginal impaction, posterior hip dislocation and stability assessment because stable and unstable posterior-wall injuries occur. | Posterior-wall size, capsular integrity, comminution, hip stability and femoral-head injury influence outcome; the Letournel label supplies no individual probability. The review explicitly notes that the classification does not encode stability. | Alton and Gee 2014, Fig. 1 and Purpose identify the elementary posterior-wall pattern and posterior approach context; Limitations discusses variable wall size, capsular injury, stability, comminution and femoral-head injury. Gansslen et al. 2024, posterior-wall fragment branch. | ✓ |
| ant-column | Anterior column (elementary) | Elementary anterior-column fracture: the anterior column is separated along a variable high-to-low course that can extend from the iliac wing or pelvic brim through the acetabulum toward the obturator ring or ischiopubic segment; the iliopectineal line is disrupted. | The pattern generally directs planning toward anterior-column access when operative reduction is indicated. Preserve the fracture height and displacement because they affect exposure; do not infer an operation solely from the anterior-column label. | This is an anatomic pattern rather than a calibrated severity category. Joint congruence, dome involvement, impaction, comminution, intra-articular fragments, associated injuries and quality of reduction drive risk more than the label alone. | Alton and Gee 2014, Fig. 1, Purpose and Conclusions identify anterior column as elementary and link pattern to approach planning. Gansslen et al. 2024, iliopectineal-line, iliac-wing, inferior-ramus and CT column analysis sections. | ✓ |
| post-column | Posterior column (elementary) | Elementary posterior-column fracture: the posterior column is separated, classically along a course from the greater sciatic-notch region through the acetabulum to the obturator or ischiopubic segment; the ilioischial line is disrupted without a separate posterior-wall component. | A posterior approach family is classically used when operative fixation is selected. The report must still state displacement, joint congruence, sciatic-notch extension, wall integrity and intra-articular injury because the pattern does not itself establish operative indication. | The category does not provide a pattern-specific probability of arthritis, nerve injury or arthroplasty. Initial displacement, articular reduction, impaction, comminution, femoral-head injury, fragments and patient factors remain the major reported outcome drivers. | Alton and Gee 2014, Fig. 1 and Purpose identify posterior column as elementary and describe posterior approach context; Limitations lists prognostic modifiers. Gansslen et al. 2024, ilioischial-line and CT column-separation analysis. | ✓ |
| transverse | Transverse (elementary) | Elementary transverse fracture: one transverse component crosses both columns and separates an inferior ischiopubic segment from a superior iliac segment whose acetabular roof remains attached to the sacroiliac joint. Record the infratectal, juxtatectal or transtectal level. | Anterior, posterior or combined access may be considered depending on fracture level, direction of displacement, hip dislocation and reducibility. The code informs approach planning but does not decide treatment; weight-bearing dome involvement and congruence must be reported. | A higher transverse level can involve more of the weight-bearing dome, but no per-level probability is encoded. Long-term outcome is strongly linked to articular congruence and reduction plus impaction, comminution and joint injury rather than the word transverse alone. | Alton and Gee 2014, Fig. 1, Purpose and approach discussion identify the transverse elementary pattern and variable approach options; Limitations covers outcome modifiers. Gansslen et al. 2024, axial-CT transverse-component and algorithm sections. | ✓ |
| post-column-wall | Posterior column with posterior wall (associated) | Associated posterior-column plus posterior-wall fracture: a complete posterior-column separation coexists with an independent posterior-wall fragment. Both components must be demonstrated; a disrupted wall line alone is insufficient. | The combined posterior column and wall anatomy commonly makes posterior access relevant when fixation is indicated. Planning must additionally address wall-fragment stability, marginal impaction, column displacement, hip dislocation and femoral-head or intra-articular injury. | Associated patterns can have worse outcomes, but this label is not a numeric prognosis. Wall comminution, femoral-head injury, instability, initial displacement and final reduction quality must be reported to characterize risk. | Alton and Gee 2014, Fig. 1 lists posterior column with posterior wall among the five associated patterns; Purpose and Limitations address approach and prognostic factors. Gansslen et al. 2024, posterior-wall-fragment branch separating PC/W from isolated posterior column. | ✓ |
| transverse-wall | Transverse with posterior wall (associated) | Associated transverse plus posterior-wall fracture: a transverse component crosses both columns and an independent posterior-wall fragment is also present. Preserve the transverse roof level and the wall-fragment size, displacement and impaction. | The transverse component and posterior wall may require posterior, anterior or combined access depending on displacement and reducibility. The pattern is an approach-planning input, not an automatic indication; assess hip stability, congruence and incarcerated fragments separately. | Risk is not calibrated by this label. Posterior-wall instability or comminution, dome involvement, femoral-head injury, intra-articular fragments, delay and quality of reduction materially affect outcome. | Alton and Gee 2014, Fig. 1 and Purpose list transverse with posterior wall as associated and describe variable approaches; Limitations lists stability and outcome factors. Gansslen et al. 2024, posterior-wall branch separating TPW from pure transverse. | ✓ |
| t-shaped | T-shaped (associated) | Associated T-shaped fracture: a transverse component is joined by a distal vertical stem that separates the anterior and posterior columns below the acetabulum, typically extending into the obturator ring or ischiopubic segment. | Approach selection is variable and may require anterior, posterior or combined access according to displacement of each limb and surgeon expertise. Map both the transverse bar and inferior stem before planning; the T-shaped code alone does not mandate a procedure. | The associated topology denotes complexity but is not an ordinal risk score. Dome involvement, fragment displacement, impaction, comminution, joint contents and achievable articular reduction determine prognosis more directly. | Alton and Gee 2014, Fig. 1 and Purpose identify T-shaped as an associated pattern with variable approach options. Gansslen et al. 2024, CT analysis and Fig. 6 describe the transverse component plus distal column separation and note classification difficulty. | ✓ |
| ant-column-post-hemitransverse | Anterior column with posterior hemitransverse (associated) | Associated anterior-column plus posterior-hemitransverse fracture: a complete anterior-column component coexists with a transverse fracture limited to the posterior acetabulum, while some articular roof remains attached to the stable posterior ilium and sacroiliac joint. | Anterior-column access is commonly relevant when fixation is indicated, with additional planning for the posterior hemitransverse component. Confirm displacement and reducibility of both components; do not equate this pattern with both-column or choose an approach from the label alone. | The label does not quantify prognosis. Outcome depends on articular displacement and reduction, impaction, comminution, intra-articular fragments, femoral-head injury and patient factors; retained roof attachment distinguishes topology, not safety. | Alton and Gee 2014, Fig. 1 and Purpose list anterior column with posterior hemitransverse and anterior approach context. Gansslen et al. 2024, CT definitions distinguish ACPHT by posterior-only transverse component and retained articular attachment to the SI joint. | ✓ |
| both-column | Associated both-column (associated) | Associated both-column fracture: the anterior and posterior columns and every acetabular articular segment are disconnected from the stable posterior ilium and sacroiliac joint, producing a floating acetabulum; the spur sign supports this complete articular dissociation. | Reconstruction may require anterior, posterior or combined strategies based on the dominant displacement and accessible reduction pathway. Confirm that no articular roof remains attached to the sacroiliac joint and map all fragments; the code alone does not select surgery or approach. | Complete articular dissociation is complex, yet the label is not a patient-specific forecast. Initial displacement, marginal impaction, comminution, intra-articular fragments, femoral-head injury, age, timing and final reduction quality govern outcome. | Alton and Gee 2014, Fig. 1, Purpose and Limitations identify both-column as associated and describe approach and outcome constraints. Gansslen et al. 2024, CT analysis and algorithm define no articular fragment attached to the SI joint and the spur sign distinction from ACPHT. | ✓ |

### Per-category citations
- **ant-wall**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, History/Purpose and Fig. 1 list anterior wall among the five elementary patterns; Purpose and Limitations address approach planning, stability and outcome modifiers. Gansslen et al. 2024, AP wall-line and Judet-view analysis.
- **post-wall**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 and Purpose identify the elementary posterior-wall pattern and posterior approach context; Limitations discusses variable wall size, capsular injury, stability, comminution and femoral-head injury. Gansslen et al. 2024, posterior-wall fragment branch.
- **ant-column**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1, Purpose and Conclusions identify anterior column as elementary and link pattern to approach planning. Gansslen et al. 2024, iliopectineal-line, iliac-wing, inferior-ramus and CT column analysis sections.
- **post-column**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 and Purpose identify posterior column as elementary and describe posterior approach context; Limitations lists prognostic modifiers. Gansslen et al. 2024, ilioischial-line and CT column-separation analysis.
- **transverse**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1, Purpose and approach discussion identify the transverse elementary pattern and variable approach options; Limitations covers outcome modifiers. Gansslen et al. 2024, axial-CT transverse-component and algorithm sections.
- **post-column-wall**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 lists posterior column with posterior wall among the five associated patterns; Purpose and Limitations address approach and prognostic factors. Gansslen et al. 2024, posterior-wall-fragment branch separating PC/W from isolated posterior column.
- **transverse-wall**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 and Purpose list transverse with posterior wall as associated and describe variable approaches; Limitations lists stability and outcome factors. Gansslen et al. 2024, posterior-wall branch separating TPW from pure transverse.
- **t-shaped**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 and Purpose identify T-shaped as an associated pattern with variable approach options. Gansslen et al. 2024, CT analysis and Fig. 6 describe the transverse component plus distal column separation and note classification difficulty.
- **ant-column-post-hemitransverse**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1 and Purpose list anterior column with posterior hemitransverse and anterior approach context. Gansslen et al. 2024, CT definitions distinguish ACPHT by posterior-only transverse component and retained articular attachment to the SI joint.
- **both-column**: Alton TB, Gee AO. Classifications in Brief: Letournel Classification for Acetabular Fractures (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3889427/ · Alton and Gee 2014, Fig. 1, Purpose and Limitations identify both-column as associated and describe approach and outcome constraints. Gansslen et al. 2024, CT analysis and algorithm define no articular fragment attached to the SI joint and the spur sign distinction from ACPHT.

## Cross-references
- _shared boundary_ → [Tile — Tile classification of pelvic ring injuries](https://radcommons.laudos.ai/systems/tile-pelvis.md) — Judet-Letournel classifies acetabular fractures; Tile classifies the pelvic ring — adjacent but distinct injuries.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1980-09-01 | revised | Letournel confirmed and refined the framework into the currently recognized five elementary and five associated patterns using a large radiographic and operative series. | confirmed |
| 1964-12-01 | published | Judet, Judet and Letournel published the radiographic column concept, acetabular fracture classification and approach-planning framework. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/letournel-acetabulum · API JSON: https://radcommons.laudos.ai/api/v1/systems/letournel-acetabulum · Agent index: https://radcommons.laudos.ai/llms.txt

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# Kellgren-Lawrence — Kellgren-Lawrence radiographic grading of osteoarthritis

> Ordinal radiographic osteoarthritis morphology based on osteophytes, joint-space loss, subchondral sclerosis and bone-end deformity. The grade must be tied to a named joint, side, compartment, projection and description/atlas lineage; it does not diagnose symptomatic osteoarthritis, identify a pain generator or prescribe treatment.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Kellgren and Lawrence / musculoskeletal epidemiology · **Version:** 1957 original; joint, projection and description lineage required · **Year:** 1957

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis (Kellgren and Lawrence) (1957) — https://doi.org/10.1136/ard.16.4.494
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Grade radiographic morphology only after fixing joint, side, projection and description lineage; expose feature-level disagreement and never use the number as a proxy for pain, clinical diagnosis, prognosis or treatment need.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, no radiographic OA features | On the named joint, side and technically adequate declared projection, no osteophyte, joint-space narrowing, subchondral sclerosis or bone-end deformity is identified under the stated Kellgren-Lawrence description. Grade 0 is not valid for an unseen compartment or an inadequately positioned image. | Report no radiographic OA features on the assessed view. If symptoms are typical, evaluate and manage the person clinically; grade 0 does not end the work-up. If symptoms are atypical, rapidly worsening or accompanied by a hot swollen joint, trauma or destructive change, pursue the appropriate alternative diagnosis rather than repeating KL grading. | Grade 0 is below the common epidemiologic threshold for definite radiographic knee OA, but it does not exclude pain, early or non-radiographic disease, patellofemoral disease missed on an AP view, or future OA. No individual progression or symptom probability is supplied by the grade. | Kohn et al. 2016, PMC4925407, Description of grade 0 and Limitations; Bedson and Croft 2008, PMC2542996, Results on clinical-radiographic discordance; NICE NG226 recommendations 1.1.1-1.1.2 and atypical-features definition. | ✓ |
| 1 | Grade 1, doubtful joint-space narrowing or possible osteophytic lipping | Doubtful joint-space narrowing and/or possible osteophytic lipping on the named joint and declared projection. The possible finding must be separated from projection, positioning and normal variation; when that cannot be done, preserve a 0-versus-1 boundary rather than claiming definite OA. | Describe the equivocal feature and acquisition limitations instead of treating grade 1 as a clinical diagnosis. Management remains based on symptoms and function, with information, therapeutic exercise and weight management when appropriate; routine imaging follow-up is not indicated solely to watch a KL number. | Grade 1 is commonly grouped with grade 0 as no or possible radiographic OA in knee research, but that convention is not a universal clinical threshold. It neither predicts pain nor provides a calibrated chance of progression to grade 2. | Kohn et al. 2016, PMC4925407, grade 1 description and threshold discussion; Schiphof et al. 2008, DOI 10.1136/ard.2007.079020, non-identical descriptions; NICE NG226 recommendations 1.2.2, 1.3.1 and 1.5.4. | ✓ |
| 2 | Grade 2, definite osteophytes with possible joint-space narrowing | Definite osteophyte formation with possible joint-space narrowing under the canonical knee description. A feature pattern with definite narrowing but no definite osteophyte exposes a known atlas/description ambiguity and must be reported with its lineage rather than silently forced into grade 2. | Record mild/definite radiographic OA morphology but do not diagnose symptomatic OA or select treatment from the image alone. For clinically diagnosed OA, guide care by pain, function, preferences and comorbidity; use exercise and weight management when appropriate, and do not routinely image for non-surgical follow-up. | Grade 2 or higher is a common epidemiologic definition of definite radiographic knee OA, not a universal proof of symptomatic disease. The category carries no fixed pain, progression, arthroplasty or survival probability for an individual. | Kohn et al. 2016, PMC4925407, grade 2 definition and definite-radiographic-OA threshold; Schiphof et al. 2008, DOI 10.1136/ard.2007.079020; Bedson and Croft 2008, PMC2542996; NICE NG226 recommendations 1.2.2 and 1.5.4. | ✓ |
| 3 | Grade 3, multiple osteophytes, definite narrowing, some sclerosis and possible deformity | Multiple or moderate osteophytes with definite joint-space narrowing, some subchondral sclerosis and possible deformity of the bone ends on the declared joint/projection. Confirm that narrowing is not chiefly a positioning or non-comparable-view artifact and name the affected compartment. | Report moderate radiographic morphology and separately document symptoms, function, alignment and alternative findings. The grade does not prescribe medication, injection or surgery. Consider joint-replacement referral only when symptoms substantially affect quality of life and non-surgical management is ineffective or unsuitable, using clinical assessment rather than this number alone. | Grade 3 establishes more advanced structural change than grade 2 but does not determine symptom intensity, treatment response or inevitability/timing of arthroplasty. Apparent longitudinal change is unreliable when views, loading or flexion differ. | Kohn et al. 2016, PMC4925407, grade 3 description and reliability limitations; NICE NG226 recommendations 1.5.4 and 1.6.1-1.6.2; Eijking et al. 2026, PMC12964767, interspecialty reliability results. | ✓ |
| 4 | Grade 4, large osteophytes, marked narrowing and sclerosis with definite deformity | Large osteophytes, marked or severe joint-space narrowing, marked or severe subchondral sclerosis and definite deformity of the bone ends on a technically adequate declared projection. Document compartment, alignment and any collapse or destructive feature that may require a separate diagnosis. | Report severe radiographic OA morphology, but do not equate it with unbearable pain or an automatic arthroplasty indication. Referral and treatment require clinical symptom/function burden, quality-of-life impact, prior non-surgical care, comorbidity, preferences and exclusion of urgent alternative pathology. | Grade 4 is the highest ordinal radiographic morphology category, not a prognosis or futility label. Some people have discordant symptoms, and the grade alone provides no individualized probability of disability, progression, surgical need or outcome. | Kohn et al. 2016, PMC4925407, grade 4 definition and Limitations; Bedson and Croft 2008, PMC2542996, symptom-radiograph discordance; NICE NG226 recommendations 1.6.1-1.6.3 and atypical-features definition. | ✓ |

### Per-category citations
- **0**: Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis (2016) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4925407/ · Kohn et al. 2016, PMC4925407, Description of grade 0 and Limitations; Bedson and Croft 2008, PMC2542996, Results on clinical-radiographic discordance; NICE NG226 recommendations 1.1.1-1.1.2 and atypical-features definition.
- **1**: Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis (2016) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4925407/ · Kohn et al. 2016, PMC4925407, grade 1 description and threshold discussion; Schiphof et al. 2008, DOI 10.1136/ard.2007.079020, non-identical descriptions; NICE NG226 recommendations 1.2.2, 1.3.1 and 1.5.4.
- **2**: Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis (2016) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4925407/ · Kohn et al. 2016, PMC4925407, grade 2 definition and definite-radiographic-OA threshold; Schiphof et al. 2008, DOI 10.1136/ard.2007.079020; Bedson and Croft 2008, PMC2542996; NICE NG226 recommendations 1.2.2 and 1.5.4.
- **3**: Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis (2016) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4925407/ · Kohn et al. 2016, PMC4925407, grade 3 description and reliability limitations; NICE NG226 recommendations 1.5.4 and 1.6.1-1.6.2; Eijking et al. 2026, PMC12964767, interspecialty reliability results.
- **4**: Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis (2016) — https://pmc.ncbi.nlm.nih.gov/articles/PMC4925407/ · Kohn et al. 2016, PMC4925407, grade 4 definition and Limitations; Bedson and Croft 2008, PMC2542996, symptom-radiograph discordance; NICE NG226 recommendations 1.6.1-1.6.3 and atypical-features definition.

## Cross-references
- _shared boundary_ → [Tönnis — Tönnis grading of hip osteoarthritis](https://radcommons.laudos.ai/systems/tonnis-hip.md) — Both can describe radiographic hip osteoarthritis, but Tonnis and Kellgren-Lawrence use distinct grade definitions and are not numerically interchangeable. Name the selected system and projection.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1957-12-01 | published | Kellgren and Lawrence published the radiographic osteoarthrosis assessment framework. Later grade wordings vary, so current records must preserve the description or atlas lineage. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/kellgren-lawrence · API JSON: https://radcommons.laudos.ai/api/v1/systems/kellgren-lawrence · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lauge-Hansen — Lauge-Hansen classification of ankle fractures

> Classifies ankle fractures by mechanism of injury.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1950 · **Year:** 1950

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations (Lauge-Hansen) (1950) — https://en.wikipedia.org/wiki/Lauge-Hansen_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| SER | Supination-external rotation | Supination-External Rotation: foot supinated (inverted) with an external rotational force. Four progressive stages: (1) anterior tibiofibular (anterior inferior tibiofibular) ligament sprain/rupture; (2) lateral short oblique fracture of the distal fibula running anteroinferior to posterosuperior; (3) posterior tibiofibular ligament rupture or posterior malleolus avulsion; (4) transverse medial malleolus fracture or deltoid ligament disruption. | Management is stage- and stability-driven: early stages with an intact medial side (e.g. SER-II, isolated distal fibula) are stable and treated nonoperatively in a cast/boot, whereas the late stage with medial malleolus fracture or deltoid disruption (SER-IV, bimalleolar-equivalent) is unstable and treated with open reduction and internal fixation to restore the mortise. | Most common ankle-fracture mechanism. Stability tracks with stage: SER-II is generally stable; SER-IV is inherently unstable because the disrupted medial restraint no longer stabilizes the mortise, predicting poor outcome if the talus is not anatomically reduced. | Stages list from Wikipedia 'Lauge-Hansen classification', Supination-external rotation section; 'most common mechanism' (up to ~85% of ankle fractures) and stability/management (SER-II stable, nonoperative vs SER-IV unstable, ORIF) from open-access PMC3229380 (managing SER type II vs IV ankle fractures). | ✓ |
| SAD | Supination-adduction | Supination-Adduction: foot supinated (inverted) with an adductive force. Two progressive stages: (1) anterior talofibular ligament sprain or transverse/avulsion fracture of the distal fibula below the joint line; (2) vertical (near-vertical) fracture of the medial malleolus with impaction of the anteromedial distal tibial plafond. | Stage 1 (isolated low fibular/lateral injury) is generally stable and treated nonoperatively. Stage 2 adds a vertical medial malleolus fracture with possible plafond impaction - this is unstable and typically requires ORIF, with attention to buttressing the vertical fragment and elevating any impacted plafond. | Stability tracks with stage: the medial-side vertical fracture and articular impaction of stage 2 make it unstable and at risk for malreduction and post-traumatic arthritis if the joint surface and mortise are not restored. | Stages list from Wikipedia 'Lauge-Hansen classification', Supination-adduction section; general stability principle (medial-side osseous injury -> instability -> ORIF) from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'. | ✓ |
| PER | Pronation-external rotation | Pronation-External Rotation: foot pronated (everted) with an external rotational force. Four progressive stages: (1) medial malleolus transverse fracture or deltoid ligament disruption; (2) anterior tibiofibular ligament disruption; (3) lateral fibular fracture above the level of the joint (high/spiral fibular fracture); (4) posterior tibiofibular ligament rupture or posterior malleolus avulsion. | PER injuries start with medial-side failure, so they are unstable from an early stage and usually need surgery: ORIF of the high (suprasyndesmotic) fibular fracture and medial malleolus, with syndesmotic fixation when the distal tibiofibular ligaments are disrupted (high Maisonneuve-type fractures). | Higher instability profile than SER: the early medial injury plus high fibular fracture and syndesmotic disruption produce a mortise-unstable ankle; missed syndesmotic injury risks chronic instability and arthritis. | Stages list from Wikipedia 'Lauge-Hansen classification', Pronation-external rotation section; stability/management principle (medial + syndesmotic disruption -> unstable -> ORIF + syndesmotic fixation) from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'. | ✓ |
| PAD | Pronation-abduction | Pronation-Abduction: foot pronated (everted) with an abductive force. Three progressive stages: (1) medial malleolus fracture or deltoid ligament disruption; (2) anterior inferior tibiofibular ligament sprain/rupture; (3) transverse, often comminuted, fracture of the fibula above the level of the syndesmosis. | Like PER, the medial side fails first, so PAD injuries are typically unstable and treated operatively: ORIF of the medial malleolus and the comminuted suprasyndesmotic fibular fracture, with syndesmotic fixation when the distal tibiofibular ligaments are disrupted. | Unstable pattern: combined medial-side injury, syndesmotic involvement, and a comminuted high fibular fracture compromise the mortise and increase the risk of malunion and post-traumatic arthritis if not anatomically fixed. | Stages list from Wikipedia 'Lauge-Hansen classification', Pronation-abduction section; stability/management principle from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'. | ✓ |

### Per-category citations
- **SER**: Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations (Lauge-Hansen) (1950) — https://en.wikipedia.org/wiki/Lauge-Hansen_classification · Stages list from Wikipedia 'Lauge-Hansen classification', Supination-external rotation section; 'most common mechanism' (up to ~85% of ankle fractures) and stability/management (SER-II stable, nonoperative vs SER-IV unstable, ORIF) from open-access PMC3229380 (managing SER type II vs IV ankle fractures).
- **SAD**: Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations (Lauge-Hansen) (1950) — https://en.wikipedia.org/wiki/Lauge-Hansen_classification · Stages list from Wikipedia 'Lauge-Hansen classification', Supination-adduction section; general stability principle (medial-side osseous injury -> instability -> ORIF) from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'.
- **PER**: Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations (Lauge-Hansen) (1950) — https://en.wikipedia.org/wiki/Lauge-Hansen_classification · Stages list from Wikipedia 'Lauge-Hansen classification', Pronation-external rotation section; stability/management principle (medial + syndesmotic disruption -> unstable -> ORIF + syndesmotic fixation) from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'.
- **PAD**: Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations (Lauge-Hansen) (1950) — https://en.wikipedia.org/wiki/Lauge-Hansen_classification · Stages list from Wikipedia 'Lauge-Hansen classification', Pronation-abduction section; stability/management principle from open-access PMC3229380 and LITFL 'Lauge-Hansen classification of ankle injury'.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lauge-hansen · API JSON: https://radcommons.laudos.ai/api/v1/systems/lauge-hansen · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lodwick — Original Lodwick grading of lytic bone-lesion growth rate

> Sequential conventional-radiograph algorithm for an evidently lytic bone lesion using destruction pattern and geographic-margin subtype, cortical penetration, complete sclerotic rim and expanded shell. It estimates relative growth/aggressiveness, not histology, malignancy certainty or a treatment order.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Lodwick et al. / musculoskeletal radiology · **Version:** Original 1980 IA-III algorithm; variants and evidence reviewed through 2025 · **Year:** 1980

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply the original ordered truth table to a lytic lesion on radiographs, return every raw descriptor, and keep later variants, histology, management and numeric risk separate.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| IA | Grade IA, single indolent geographic descriptor combination | This is the single original grade-IA combination: an evidently lytic geographic lesion with a regular, lobulated or multicentric margin; absent or partial rather than total cortical penetration; a complete sclerotic rim; and no expanded shell or expansion no greater than 1 cm beyond the expected normal contour. Every element must be supported on adequate radiographs. | Describe the full morphology and compare prior radiographs. A confidently classic benign diagnosis may require no additional workup, but IA itself is not a leave-alone command. Symptoms, age, bone and segment, matrix, periosteal reaction, multiplicity, fracture and any discordant feature determine whether observation, comparison, CT, MRI or specialist review is appropriate. | IA is the slowest-growth end of the original ordinal scale and generally carries the lowest malignancy concern, but it does not prove benignity. The often cited 94% benign figure combines IA and IB in a retrospective modified-system grade-I cohort and must not be presented as an IA-specific probability. | Lodwick et al. 1980, DOI 10.1148/radiology.134.3.6928321, original truth table; Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 item 6 for the only IA combination; Caracciolo et al. 2016 abstract for the non-IA-specific modified grade-I cohort. | ✓ |
| IB | Grade IB, other geographic pattern without total cortical penetration | The lesion is geographic, has no moth-eaten margin and has absent or partial cortical penetration, but fails the unique IA combination. IB includes a ragged or poorly defined geographic margin without total penetration, an absent or incomplete sclerotic rim, or an expanded shell greater than 1 cm when earlier higher-priority destruction-pattern branches do not apply. | Return which descriptor caused IB and integrate the complete lesion and patient context. Because IB spans several morphologies and reader agreement is limited, it cannot alone select surveillance interval or rule out further characterization; discordant clinical or imaging features may warrant CT, MRI or musculoskeletal-oncology review under current workup guidance. | IB denotes faster inferred growth or less secure benign morphology than IA but has no validated subtype-specific malignancy percentage. The 94% benign estimate belongs to IA plus IB combined in the modified Lodwick-Madewell grade-I cohort; using it as an individual IB probability would overstate precision. | Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 4-5 for greater-than 1 cm shell and incomplete rim, plus the direct IB branch for ragged/poorly defined margin without total cortical penetration; Caracciolo et al. 2016 for modified-system context. | ✓ |
| IC | Grade IC, thin moth-eaten margin or total cortical penetration | The lesion remains fundamentally geographic but has either a moth-eaten margin no greater than 1 cm or total cortical penetration. Total penetration assigns IC regardless of a regular, lobulated, multicentric, ragged or poorly defined geographic margin unless an earlier branch already established a moth-eaten margin greater than 1 cm (grade II) or any permeative component (grade III). | Treat IC as an indeterminate-to-aggressive radiographic pattern requiring complete characterization and appropriate specialist workup, not as a histologic diagnosis. Current ACR guidance generally supports MRI or CT after an indeterminate or aggressive radiographic lesion for extent, viability and biopsy or surgical planning; the exact study and need for biopsy depend on the whole case. | IC has greater malignancy concern than IA/IB but no reliable original-IC bedside probability. The 2016 modified system reassigns original IC to its grade II because its cohort showed an approximately even benign/malignant distribution in that modified middle tier; this variant evidence cannot be silently relabeled as an original-IC probability. | Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 2-3 for a thin moth-eaten margin and total cortex penetration; Subsequent works for reclassification of original IC in the 2016 variant; ACR Suspected Primary Bone Tumors 2024 Update, indeterminate/aggressive radiograph variant. | ✓ |
| II | Grade II, moth-eaten pattern or wide moth-eaten margin | The destruction pattern is moth-eaten—multiple randomly distributed lytic holes of nonuniform size—or a dominant geographic lesion has a moth-eaten marginal zone greater than 1 cm. This branch takes priority over geographic cortical, rim and shell assessment, but any permeative component anywhere upgrades the original pattern to grade III. | Report the aggressive destruction pattern and promptly integrate matrix, periosteal reaction, soft-tissue extension, fracture, multiplicity, age and symptoms. Further local staging and specialist referral are commonly appropriate for an indeterminate/aggressive radiographic lesion, but grade II itself does not choose imaging protocol, biopsy route, surgery or oncologic therapy. | Grade II indicates rapid inferred growth and substantial concern for aggressive neoplasm or another aggressive process, but the original scale supplies no universal grade-II malignancy percentage. Infection and other mimics remain possible, and the 2025 reader study demonstrates poor overall interobserver reliability. | Lodwick et al. 1980 original truth table; Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 4 and Pitfalls/Table 2 item 2 for entirely moth-eaten or greater-than 1 cm moth-eaten margin; Willenbring et al. 2025 for reliability limits; ACR 2024 Update for workup context. | ✓ |
| III | Grade III, any permeative component | Multiple uniformly small permeative holes are present anywhere in the lytic lesion. Even a small permeative focus in an otherwise geographic lesion makes the original Lodwick grade III; the more indolent-appearing majority must not erase this highest-priority destruction pattern. | Communicate the permeative component and pursue urgent, appropriately coordinated characterization of an aggressive lesion, including local staging and musculoskeletal-oncology input when indicated. The grade is not proof of malignancy and must not trigger an unplanned biopsy; biopsy trajectory and definitive management require specialist planning. | III is the fastest-growth and highest-concern original category, but some benign or nonneoplastic processes can appear permeative. The cited 81% malignant figure comes from a retrospective modified-system grade III that pooled original II/III with changing-margin and radiographically occult patterns, so it is cohort and variant context rather than an original grade-III individual probability. | Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 3 and Pitfalls/Table 2 item 1 for any permeative component; Caracciolo et al. 2016 abstract for the composition and 81% malignant rate of modified grade III; ACR 2024 Update for aggressive-lesion imaging context. | ✓ |

### Per-category citations
- **IA**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Lodwick et al. 1980, DOI 10.1148/radiology.134.3.6928321, original truth table; Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 item 6 for the only IA combination; Caracciolo et al. 2016 abstract for the non-IA-specific modified grade-I cohort.
- **IB**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 4-5 for greater-than 1 cm shell and incomplete rim, plus the direct IB branch for ragged/poorly defined margin without total cortical penetration; Caracciolo et al. 2016 for modified-system context.
- **IC**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 2-3 for a thin moth-eaten margin and total cortex penetration; Subsequent works for reclassification of original IC in the 2016 variant; ACR Suspected Primary Bone Tumors 2024 Update, indeterminate/aggressive radiograph variant.
- **II**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Lodwick et al. 1980 original truth table; Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 4 and Pitfalls/Table 2 item 2 for entirely moth-eaten or greater-than 1 cm moth-eaten margin; Willenbring et al. 2025 for reliability limits; ACR 2024 Update for workup context.
- **III**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 3 and Pitfalls/Table 2 item 1 for any permeative component; Caracciolo et al. 2016 abstract for the composition and 81% malignant rate of modified grade III; ACR 2024 Update for aggressive-lesion imaging context.

## Cross-references
- _shared boundary_ → [Bone-RADS — Bone Reporting and Data System](https://radcommons.laudos.ai/systems/bone-rads.md) — Original Lodwick grades radiographic lytic-lesion growth morphology. Bone-RADS is a separate CT/MRI management framework; the numbers are not interchangeable.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1980-03-01 | published | Lodwick and colleagues published the original IA, IB, IC, II and III radiographic growth-rate truth table for focal lytic bone lesions. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lodwick · API JSON: https://radcommons.laudos.ai/api/v1/systems/lodwick · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Mason — Mason classification of radial head fractures

> Classifies radial head fractures by displacement and comminution.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1954 · **Year:** 1954

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Mason ML. Some difficulties in the treatment of fractures of the radial head (Mason) (1954) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3348319/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Non-displaced (or minimally displaced) radial head fracture — a fissure (crack) or marginal/peripheral fracture of the rim without displacement. | Nonoperative: brief immobilization in a sling/splint (on the order of days to ~2 weeks) followed by early active range of motion. | Favorable prognosis; one large series reported about 95% excellent or good outcomes with conservative care. | PMC3348319 (Morrey-context 'In Brief: The Mason Classification of Radial Head Fractures'), Treatment/Outcomes, Type 1. | ✓ |
| II | Type II | Marginal (partial articular) sector fracture of the lateral radial head that is displaced — separated from adjacent quadrants, impacted/depressed, or tilted out of alignment. | Variable, no firm consensus: nonoperative early mobilization for stable fractures without a mechanical block, versus open reduction and internal fixation (or fragment excision) when displacement is larger or motion is blocked. | Outcomes are variable; fractures are often more comminuted than they appear (three or more fragments in about 73% in one series), which can complicate repair. | PMC3348319 Treatment/Outcomes, Type 2. | ✓ |
| III | Type III | Comminuted fracture involving the whole radial head, with fragmentation and displacement of the entire head. | Operative: radial head excision, or open reduction and internal fixation versus radial head arthroplasty/replacement depending on reconstructability and elbow stability. | Generally requires surgery; comparative outcome data favoring one surgical strategy over another are limited. | PMC3348319 Treatment/Outcomes, Type 3. | ✓ |
| IV | Type IV | Any radial head fracture with a concomitant elbow dislocation, irrespective of the radial head fracture pattern (added by Johnston, 1962; later incorporated by Broberg and Morrey). | Operative and highly variable: ranges from closed management through ORIF to radial head excision or prosthetic replacement, with attention to restoring elbow stability and treating associated ligamentous/coronoid injury. | Higher-energy injury with associated instability; prognosis not specified per-type in the source. | PMC3348319 Type IV (Broberg-Morrey modification) Treatment section. | ✓ |

### Per-category citations
- **I**: Mason ML. Some difficulties in the treatment of fractures of the radial head (Mason) (1954) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3348319/ · PMC3348319 (Morrey-context 'In Brief: The Mason Classification of Radial Head Fractures'), Treatment/Outcomes, Type 1.
- **II**: Mason ML. Some difficulties in the treatment of fractures of the radial head (Mason) (1954) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3348319/ · PMC3348319 Treatment/Outcomes, Type 2.
- **III**: Mason ML. Some difficulties in the treatment of fractures of the radial head (Mason) (1954) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3348319/ · PMC3348319 Treatment/Outcomes, Type 3.
- **IV**: Mason ML. Some difficulties in the treatment of fractures of the radial head (Mason) (1954) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3348319/ · PMC3348319 Type IV (Broberg-Morrey modification) Treatment section.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mason · API JSON: https://radcommons.laudos.ai/api/v1/systems/mason · Agent index: https://radcommons.laudos.ai/llms.txt

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# Mirels — Mirels scoring for impending pathologic fracture

> Scores risk of pathologic fracture in long bone metastases.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1989 · **Year:** 1989

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Mirels H. Metastatic disease in long bones: a proposed scoring system (Mirels) (1989) — https://doi.org/10.1097/00003086-198912000-00027
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| <=7 | Low risk | Total Mirels score of 7 or less. The score sums four variables each rated 1-3: site (1 upper limb, 2 lower limb, 3 peritrochanteric), pain (1 mild, 2 moderate, 3 functional/mechanical), lesion nature (1 blastic, 2 mixed, 3 lytic), and lesion size as fraction of cortex (1 under 1/3, 2 between 1/3 and 2/3, 3 over 2/3). | Low fracture risk; managed conservatively with analgesia and radiotherapy plus observation. Prophylactic internal fixation is generally not indicated. | Low probability of pathologic fracture; a score of 7 corresponds to about a 4% fracture risk, so lesions in this band are considered safe to irradiate without prophylactic fixation. | Criteria/management: PMC3049613, Mirels' Staging System, Table 1 (variables) and Table 2 (<=7 = irradiate/observe). Risk figure (score 7 ~4%): PMC3049613 Table 2, corroborated by PMC11941509. | ✓ |
| 8 | Borderline | Total Mirels score of exactly 8 (intermediate band), summed from the four variables (site, pain, lesion nature, lesion size), each scored 1-3. | Borderline / clinical dilemma: decision between prophylactic fixation and conservative treatment rests on clinical judgment, since only a minority of these lesions fracture. | Approximately 15% probability of pathologic fracture - intermediate risk that does not clearly favor either fixation or conservative care. | Criteria/management: PMC3049613, Mirels' Staging System, Table 2 (8 = clinical judgment). Risk figure (~15%): PMC3049613 Table 2, corroborated by PMC11941509. | ✓ |
| >=9 | High risk, prophylactic fixation advised | Total Mirels score of 9 or greater (high band), summed from the four variables (site, pain, lesion nature, lesion size), each scored 1-3. | Prophylactic internal fixation is indicated, ideally performed before irradiation to stabilize the impending pathologic fracture. | High probability of pathologic fracture; a score of 9 corresponds to about a 33% fracture risk (rising further with higher scores), justifying prophylactic stabilization. | Criteria/management: PMC3049613, Mirels' Staging System, Table 2 (>=9 = prophylactic fixation). Risk figure (score 9 ~33%): PMC3049613 Table 2, corroborated by PMC11941509. | ✓ |

### Per-category citations
- **<=7**: Mirels H. Metastatic disease in long bones: a proposed scoring system (Mirels) (1989) — https://doi.org/10.1097/00003086-198912000-00027 · Criteria/management: PMC3049613, Mirels' Staging System, Table 1 (variables) and Table 2 (<=7 = irradiate/observe). Risk figure (score 7 ~4%): PMC3049613 Table 2, corroborated by PMC11941509.
- **8**: Mirels H. Metastatic disease in long bones: a proposed scoring system (Mirels) (1989) — https://doi.org/10.1097/00003086-198912000-00027 · Criteria/management: PMC3049613, Mirels' Staging System, Table 2 (8 = clinical judgment). Risk figure (~15%): PMC3049613 Table 2, corroborated by PMC11941509.
- **>=9**: Mirels H. Metastatic disease in long bones: a proposed scoring system (Mirels) (1989) — https://doi.org/10.1097/00003086-198912000-00027 · Criteria/management: PMC3049613, Mirels' Staging System, Table 2 (>=9 = prophylactic fixation). Risk figure (score 9 ~33%): PMC3049613 Table 2, corroborated by PMC11941509.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mirels · API JSON: https://radcommons.laudos.ai/api/v1/systems/mirels · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Myerson Lisfranc — Original Myerson-modified Hardcastle classification of Lisfranc fracture-dislocations

> Per-foot morphology classification of displaced tarsometatarsal fracture-dislocations into total incongruity, medial or lateral partial incongruity, and partial or total divergence. The original five-pattern system communicates displacement topology but does not encode subtle-injury stability, ligament integrity, treatment indication or prognosis by itself.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Myerson, Fisher, Burgess and Kenzora · **Version:** Original 1986 five-pattern A-C system; later type D kept separate · **Year:** 1986

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the original five A-C patterns only, pair every code with anatomy, and keep subtle-injury stability, later type D, prognosis and treatment as separate layers.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Type A, total incongruity | Total incongruity: the bases of all five metatarsals are displaced together in the same direction, classically homolateral lateral displacement but potentially dorsoplantar displacement. This is a displacement pattern of the entire tarsometatarsal complex, not merely widening of the Lisfranc interval. | Obtain urgent foot-and-ankle specialist assessment and separately report reduction status, soft-tissue condition, fractures, comminution, neurovascular findings and physiologic stability. A displaced total-incongruity injury commonly requires reduction and stabilization, but the A label alone does not select fixation versus fusion or dictate timing; threatened skin, open injury, compartment syndrome or neurovascular compromise drives urgent action independently. | The pattern represents extensive tarsometatarsal incongruity, but no validated contemporary probability of arthritis, fusion, reoperation or functional loss belongs to type A alone. In the historical 1986 cohort, reduction quality and late instability or degeneration were major outcome determinants across types; those center-era results cannot be converted into an individual type-A forecast. | Myerson et al. 1986, DOI 10.1177/107110078600600504, primary A-C classification and outcome discussion; Siddiqui et al. 2014, DOI 10.1148/rg.342125215, Myerson Table 2 and total-incongruity description; current ACR Acute Trauma to the Foot for imaging escalation. | ✓ |
| B1 | Type B1, medial partial incongruity | Partial or isolated incongruity with medial displacement of the first metatarsal base at the first tarsometatarsal joint, while the lateral four metatarsal bases are not part of a divergent displacement pattern. Confirm the first-ray direction across adequate projections rather than inferring B1 from an isolated fracture. | Describe first-ray displacement, articular injury, reducibility, ligamentous and bony components and any instability under load when that can be assessed safely. Specialist management depends on true displacement or instability, cartilage injury, soft tissue and patient context. The morphology code supports planning but does not autonomously mandate one operation, and a reduced injury can remain unstable despite losing the original B1 appearance. | B1 has no portable per-type risk percentage. A partial pattern can be clinically consequential despite involving fewer rays, and missed or inadequately reduced instability can lead to painful post-traumatic degeneration. Prognosis depends more directly on recognition, anatomic alignment, ligament and cartilage injury, energy, treatment and follow-up than on the B1 token by itself. | Myerson et al. 1986, primary partial-incongruity framework; Siddiqui et al. 2014, Myerson Table 2, isolated first-tarsometatarsal displacement; Mahmoud et al. 2015 and Engelmann et al. 2023 for limits of observer reliability and applicability. | ✓ |
| B2 | Type B2, lateral partial incongruity | Partial or isolated incongruity with lateral displacement of one or more of the lateral four metatarsal bases, M2 through M5, without medial displacement of M1 creating divergence. State which rays and tarsometatarsal joints are involved because the same B2 code can represent different anatomic extents. | Report the involved lateral rays, occult fractures or comminution on CT when relevant, and assess first-ray position carefully because uncertain medial M1 displacement creates the B2-versus-C1 boundary. Management is based on displacement and instability, bony versus ligamentous anatomy, reducibility and patient factors; do not turn B2 into a universal procedure or infer stability from nonweightbearing alignment alone. | B2 can be subtle and therefore vulnerable to delayed recognition, but the classification supplies no validated B2-specific probability of poor outcome. Later series have not produced a universally transportable per-type prognosis. Preserve detection confidence, alignment, instability, cartilage injury and treatment quality rather than telling an agent that B2 is intrinsically the best or worst outcome group. | Myerson et al. 1986, primary partial-incongruity classification; Siddiqui et al. 2014, Myerson Table 2 and discussion of lesser-metatarsal displacement; ACR Acute Trauma to the Foot Variant 5 for CT or MRI when radiographs are normal or equivocal. | ✓ |
| C1 | Type C1, partial divergence | Partial divergent incongruity: M1 is displaced medially while fewer than all four lateral metatarsal bases are displaced laterally. The divergence direction and the count of affected lateral rays distinguish C1 from B2 and C2; when M1 direction or the full lateral column is not evaluable, retain that boundary uncertainty. | Divergence generally warrants prompt specialist review, careful soft-tissue assessment and anatomic characterization for reduction and stabilization planning. The code does not select a specific operation. CT can map fractures and comminution, while weightbearing evaluation or MRI may be needed for a separate stability or ligament question when safe and clinically appropriate. | C1 communicates a divergent injury but is not a calibrated risk stratum. Extent of joint involvement, high-energy or crush mechanism, articular damage, persistent instability, reduction quality and complications dominate outcome. Historical aggregate outcomes from displaced injuries and modern reliability studies must not be represented as a C1-specific probability. | Myerson et al. 1986, primary divergent subdivision; Siddiqui et al. 2014, Myerson Table 2, M1 medial with partial lateral-ray divergence; Mahmoud et al. 2015 and Engelmann et al. 2023 for reliability context. | ✓ |
| C2 | Type C2, total divergence | Total divergent incongruity: M1 is displaced medially and all four lateral metatarsal bases, M2 through M5, are displaced laterally. This differs from type A because the rays diverge rather than moving together in one homolateral direction. | Provide urgent specialist assessment, describe full-column displacement, fractures, articular comminution, soft-tissue threat, reduction status and associated injuries, and act immediately on open injury, neurovascular compromise or compartment syndrome. Extensive divergence often requires operative restoration of alignment, but C2 alone does not determine fixation method, fusion, timing or prognosis. | C2 denotes extensive divergent incongruity and plausibly high anatomic burden, yet the system contains no validated C2-specific rate of amputation, arthritis, fusion or disability. In the original high-energy cohort, direct crush injury and inadequate alignment were adverse across the series. Mechanism, soft tissue, cartilage, reduction and rehabilitation must remain explicit risk inputs. | Myerson et al. 1986, primary C2 definition and historical pathology, treatment and outcome correlations; Siddiqui et al. 2014, Myerson Table 2, complete divergent pattern; current ACR imaging pathway for unresolved or occult injury. | ✓ |

### Per-category citations
- **A**: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/ · Myerson et al. 1986, DOI 10.1177/107110078600600504, primary A-C classification and outcome discussion; Siddiqui et al. 2014, DOI 10.1148/rg.342125215, Myerson Table 2 and total-incongruity description; current ACR Acute Trauma to the Foot for imaging escalation.
- **B1**: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/ · Myerson et al. 1986, primary partial-incongruity framework; Siddiqui et al. 2014, Myerson Table 2, isolated first-tarsometatarsal displacement; Mahmoud et al. 2015 and Engelmann et al. 2023 for limits of observer reliability and applicability.
- **B2**: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/ · Myerson et al. 1986, primary partial-incongruity classification; Siddiqui et al. 2014, Myerson Table 2 and discussion of lesser-metatarsal displacement; ACR Acute Trauma to the Foot Variant 5 for CT or MRI when radiographs are normal or equivocal.
- **C1**: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/ · Myerson et al. 1986, primary divergent subdivision; Siddiqui et al. 2014, Myerson Table 2, M1 medial with partial lateral-ray divergence; Mahmoud et al. 2015 and Engelmann et al. 2023 for reliability context.
- **C2**: Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment (1986) — https://pubmed.ncbi.nlm.nih.gov/3710321/ · Myerson et al. 1986, primary C2 definition and historical pathology, treatment and outcome correlations; Siddiqui et al. 2014, Myerson Table 2, complete divergent pattern; current ACR imaging pathway for unresolved or occult injury.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2018-02-13 | revised | Sivakumar and colleagues proposed type D for subtle Lisfranc injuries, with D1 and D2 stability categories and D2L/D2B subtypes; this event is tracked as a noninterchangeable extension rather than silently altering the original five-code output. | confirmed |
| 1986-04-01 | published | Myerson, Fisher, Burgess and Kenzora published the five-pattern A, B1, B2, C1 and C2 modification of the Hardcastle Lisfranc fracture-dislocation framework. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/myerson-lisfranc · API JSON: https://radcommons.laudos.ai/api/v1/systems/myerson-lisfranc · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Neer — Neer classification of proximal humerus fractures

> Classifies proximal humerus fractures by displaced parts.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1970 · **Year:** 1970

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Neer CS. Displaced proximal humeral fractures (Neer) (1970) — https://www.ncbi.nlm.nih.gov/books/NBK470346/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1-part | One-part | Fracture lines may run through one to four of the anatomic segments, but no segment meets displacement criteria — every fragment is displaced less than 1 cm and angulated less than 45 degrees relative to the others. Treated as a single (minimally displaced) injury regardless of how many fracture lines are present; the soft-tissue envelope holds the fragments together. | Nonoperative: sling immobilization followed by early gentle, progressive rehabilitation. The overwhelming majority of proximal humerus fractures are minimally displaced one-part injuries and are managed conservatively with good functional results. | Generally favorable prognosis; osteonecrosis of the humeral head is uncommon because the head blood supply is usually preserved when fragments are minimally displaced. | StatPearls NBK470346, Treatment/Management — minimally displaced fractures managed with sling and progressive rehabilitation; corroborated by PMC3528923 (Carofino & Leopold, 'Classifications in Brief: The Neer Classification', CORR 2013), one-part definition. | ✓ |
| 2-part | Two-part | Exactly one of the four anatomic segments (greater tuberosity, lesser tuberosity, or articular/head segment at the anatomic or surgical neck) is displaced beyond threshold — more than 1 cm of displacement or more than 45 degrees of angulation — while the remaining fragments stay within threshold. | Depends on which segment is displaced. Minimally displaced surgical/anatomic-neck patterns may be managed nonoperatively in a sling; significantly displaced two-part fractures (e.g., displaced greater tuberosity, often >5 mm, or displaced surgical neck) are commonly treated operatively with ORIF (plate/screws, intramedullary nail, or tension-band/suture fixation). | Lower osteonecrosis risk than three- and four-part fractures because at least three segments remain in continuity, preserving humeral-head perfusion; displaced greater-tuberosity fragments risk malunion and subacromial impingement if not reduced. | StatPearls NBK470346, Treatment/Management (sling for minimally displaced surgical/anatomic-neck fractures; operative indications for displaced fractures); two-part definition corroborated by PMC3528923. | ✓ |
| 3-part | Three-part | Two segments are displaced beyond threshold — typically one tuberosity together with a displaced surgical-neck fracture (the articular segment stays attached to the remaining tuberosity), with displacement more than 1 cm or angulation more than 45 degrees. | Operative treatment is generally favored, especially in younger/active patients: open reduction and internal fixation (locking plate or intramedullary nail) to restore alignment and tuberosity position. Truly minimally displaced cases may be treated nonoperatively. | Higher osteonecrosis risk than two-part fractures because the articular blood supply is increasingly compromised as more segments displace. Published humeral-head avascular-necrosis rates for three-/four-part fractures vary widely by series and treatment (e.g. around 9% with conservative management); no single reliable per-type figure is established, and later work found fracture-part count alone does not consistently predict AVN. | StatPearls NBK470346, Treatment/Management (ORIF indicated for three-part fractures, particularly in younger patients); three-part definition, worsening vascular compromise, and the caveat that part-count does not consistently predict AVN from PMC3528923 (Carofino & Leopold, CORR 2013); ~9% conservative-treatment AVN from the systematic review PMC7444241. | ✓ |
| 4-part | Four-part | All four segments — both tuberosities, the articular surface, and the shaft — are displaced beyond threshold (more than 1 cm or more than 45 degrees), leaving four separate displaced parts. The articular fragment is typically devascularized (except in valgus-impacted variants, where the medial periosteal hinge may preserve perfusion). | Operative: in elderly patients with poor bone quality or a devascularized head, arthroplasty (originally hemiarthroplasty, now frequently reverse total shoulder arthroplasty) is favored; in younger patients with reconstructable bone, ORIF may be attempted. Valgus-impacted four-part variants can be amenable to head-preserving fixation. | Highest osteonecrosis risk of the Neer types: Neer reported avascular necrosis of the humeral head in greater than 50% of classic four-part fractures, the rationale for primary arthroplasty in many elderly patients. Valgus-impacted variants carry a lower AVN risk. | StatPearls NBK470346, Treatment/Management (arthroplasty for four-part fractures and fracture-dislocations, head impression >40%/articular blood-supply loss); 'AVN in greater than 50% of these [classic four-part] fractures' and valgus-impacted exception from PMC3528923. | ✓ |

### Per-category citations
- **1-part**: Neer CS. Displaced proximal humeral fractures (Neer) (1970) — https://www.ncbi.nlm.nih.gov/books/NBK470346/ · StatPearls NBK470346, Treatment/Management — minimally displaced fractures managed with sling and progressive rehabilitation; corroborated by PMC3528923 (Carofino & Leopold, 'Classifications in Brief: The Neer Classification', CORR 2013), one-part definition.
- **2-part**: Neer CS. Displaced proximal humeral fractures (Neer) (1970) — https://www.ncbi.nlm.nih.gov/books/NBK470346/ · StatPearls NBK470346, Treatment/Management (sling for minimally displaced surgical/anatomic-neck fractures; operative indications for displaced fractures); two-part definition corroborated by PMC3528923.
- **3-part**: Neer CS. Displaced proximal humeral fractures (Neer) (1970) — https://www.ncbi.nlm.nih.gov/books/NBK470346/ · StatPearls NBK470346, Treatment/Management (ORIF indicated for three-part fractures, particularly in younger patients); three-part definition, worsening vascular compromise, and the caveat that part-count does not consistently predict AVN from PMC3528923 (Carofino & Leopold, CORR 2013); ~9% conservative-treatment AVN from the systematic review PMC7444241.
- **4-part**: Neer CS. Displaced proximal humeral fractures (Neer) (1970) — https://www.ncbi.nlm.nih.gov/books/NBK470346/ · StatPearls NBK470346, Treatment/Management (arthroplasty for four-part fractures and fracture-dislocations, head impression >40%/articular blood-supply loss); 'AVN in greater than 50% of these [classic four-part] fractures' and valgus-impacted exception from PMC3528923.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/neer · API JSON: https://radcommons.laudos.ai/api/v1/systems/neer · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Outerbridge — Outerbridge classification of articular cartilage lesions

> Grades one articular-cartilage lesion by direct visual and tactile morphology from softening through exposed subchondral bone. MRI use is an adaptation and must retain its modality and operational thresholds.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Outerbridge · **Version:** 1961 original arthroscopic system; MRI adaptations must be labeled · **Year:** 1961

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Arthroscopy, MRI
- Primary source: Outerbridge RE. The etiology of chondromalacia patellae (1961) — https://pubmed.ncbi.nlm.nih.gov/14038135/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Retain the observation method. Apply the original diameter and bone-exposure boundaries only when supported, label MRI adaptations, and never turn this macroscopic grade into autonomous treatment or prognosis.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, normal intact cartilage | Conventional Grade 0: normal, intact articular cartilage at the named surface, without softening, swelling, fragmentation, fissuring, erosion or exposed subchondral bone. Grade 0 is the later conventional normal state; the original 1961 lesion grades were I-IV. | Document the inspected surface and assessment method. A Grade 0 surface requires no cartilage-lesion action from this scale, but it neither excludes another lesion elsewhere nor determines management of pain, instability, alignment, meniscal disease or another joint abnormality. | Grade 0 denotes no macroscopic lesion at the assessed surface, not a zero probability of symptoms, biochemical cartilage change or future degeneration. Outerbridge supplies no calibrated risk estimate for a normal-appearing surface. | Slattery and Kweon 2018, PMC6259817, Description and Fig. 1 define the conventional Grade 0 as normal cartilage; History explains that the original system was based on direct visualization and later expanded beyond the patella. | ✓ |
| I | Grade I, softening and swelling | Grade I: articular cartilage softening and swelling without the fragmentation or fissuring of Grade II and without subchondral-bone exposure. In the original macroscopic method, confident recognition commonly requires tactile feedback with a probe even when the surface looks intact. | Report the exact surface, extent and whether softening was directly probed. Grade I alone does not prescribe observation, chondroplasty or cartilage repair; management depends on symptoms and the lesion, patient and whole-joint context. | This is the earliest macroscopic lesion grade, but the classification does not assign a probability of pain, progression or treatment failure. MRI signal change cannot reproduce tactile softening and should be labeled as a modified-MRI assessment with limited confidence. | Slattery and Kweon 2018, PMC6259817, Description defines Grade I as softening and swelling and explains the need for tactile probe feedback; Limitations highlights difficulty and variable reliability for this grade and states that the system does not provide treatment guidance or clear prognosis. | ✓ |
| II | Grade II, partial-thickness fissuring not greater than 0.5 inch | Grade II: a partial-thickness cartilage defect with fragmentation or fissuring whose maximum surface diameter does not exceed 0.5 inch, approximately 12.7 mm, and which does not reach or expose subchondral bone. Preserve the measured diameter instead of rounding to force the threshold. | State location, maximum diameter, estimated area, depth, stability and associated joint findings. The Grade II label is descriptive and cannot by itself select debridement, marrow stimulation, grafting or rehabilitation. | Grade II is more extensive than softening alone but is not a validated patient-specific prognostic stratum. The II-III diameter boundary has limited reader reliability, so a near-threshold lesion should retain the measurement and adjacent-grade uncertainty. | Slattery and Kweon 2018, PMC6259817, Description defines the partial-thickness Grade II lesion and the 0.5-inch limit; Validation and Limitations discuss reader variability and difficulty separating Grades II and III by lesion size. | ✓ |
| III | Grade III, deep fissuring greater than 0.5 inch without bone exposure | Grade III: deep cartilage fragmentation or fissuring greater than 0.5 inch, approximately 12.7 mm, in maximum surface diameter, extending down toward subchondral bone but without unequivocal bone exposure. Bone exposure changes the grade to IV regardless of diameter. | Map the full lesion and any unstable flap, delamination or opposing lesion, then integrate symptoms, containment, subchondral bone, alignment, meniscus, age and activity in specialist planning. Grade III alone does not mandate a named procedure. | Some cohorts associate Grade III-IV lesions with worse outcomes after specific meniscal, hip or shoulder arthroscopic procedures, but those are context-dependent associations. Outerbridge provides no universal per-grade probability of progression, pain or failed treatment. | Slattery and Kweon 2018, PMC6259817, Description defines Grade III by fissuring over 0.5 inch extending down to subchondral bone; Validation summarizes procedure-specific outcome associations; Limitations rejects a clear prognostic or treatment rule. | ✓ |
| IV | Grade IV, exposed subchondral bone | Grade IV: full-thickness erosion of articular cartilage with exposed underlying subchondral bone. Exposure of bone is the defining feature and overrides the Grade II-III diameter boundary; record the size of the exposed component separately. | Report the exposed-bone area, lesion containment, location, opposing surface, reactive bone change and whole-joint mechanics. The severe morphology is clinically important, but the code alone cannot determine cartilage restoration, osteotomy, arthroplasty or conservative care. | Grade IV is the maximum macroscopic grade and procedure-specific cohorts group Grade III-IV with worse outcomes, yet the scale is not a calibrated prognosis. Symptoms and outcome depend on lesion extent, site, bone, alignment, meniscus, patient factors and selected treatment. | Slattery and Kweon 2018, PMC6259817, Description defines Grade IV by erosion exposing subchondral bone; Validation and Limitations describe limited prognostic associations, variable reliability and the absence of grade-directed treatment guidance. | ✓ |

### Per-category citations
- **0**: Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259817/ · Slattery and Kweon 2018, PMC6259817, Description and Fig. 1 define the conventional Grade 0 as normal cartilage; History explains that the original system was based on direct visualization and later expanded beyond the patella.
- **I**: Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259817/ · Slattery and Kweon 2018, PMC6259817, Description defines Grade I as softening and swelling and explains the need for tactile probe feedback; Limitations highlights difficulty and variable reliability for this grade and states that the system does not provide treatment guidance or clear prognosis.
- **II**: Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259817/ · Slattery and Kweon 2018, PMC6259817, Description defines the partial-thickness Grade II lesion and the 0.5-inch limit; Validation and Limitations discuss reader variability and difficulty separating Grades II and III by lesion size.
- **III**: Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259817/ · Slattery and Kweon 2018, PMC6259817, Description defines Grade III by fissuring over 0.5 inch extending down to subchondral bone; Validation summarizes procedure-specific outcome associations; Limitations rejects a clear prognostic or treatment rule.
- **IV**: Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259817/ · Slattery and Kweon 2018, PMC6259817, Description defines Grade IV by erosion exposing subchondral bone; Validation and Limitations describe limited prognostic associations, variable reliability and the absence of grade-directed treatment guidance.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 1998-09-01 | revised | A prospective MRI-to-arthroscopy study operationalized a five-point Outerbridge assessment on specialized knee MRI; MRI use remains an adaptation of the macroscopic system. | confirmed |
| 1961-11-01 | published | Outerbridge published the original direct-visualization grading framework for chondromalacia patellae. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/outerbridge · API JSON: https://radcommons.laudos.ai/api/v1/systems/outerbridge · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Pauwels — Pauwels classification of femoral neck fractures

> Classifies femoral neck fractures by the angle of the fracture line from the horizontal, predicting shear and nonunion risk.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Pauwels · **Version:** 1935 · **Year:** 1935

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Wikipedia contributors. Pauwel's angle (2026) — https://en.wikipedia.org/wiki/Pauwel's_angle
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I (low angle) | Femoral neck fracture line oriented less than 30 degrees from the horizontal on the AP radiograph (Pauwel's angle <30 degrees). | The least vertical, most stable pattern; lowest shear, generally amenable to internal fixation. | Lower fracture-line angle means lower shear stress at the fracture and the lowest nonunion risk of the three grades. | Wikipedia 'Pauwel's angle', classification table (type I <30 degrees) and Clinical Use section ('An increasing angle leads to a more unstable fracture and an increase in the shear stress... higher rates of nonunion'). | ✓ |
| II | Type II (intermediate angle) | Fracture line oriented between 30 and 50 degrees from the horizontal (Pauwel's angle 30-50 degrees). | Intermediate obliquity; Pauwels recommended internal fixation for fractures with inclination angles of 30-50 degrees. | Intermediate shear stress and nonunion risk, between types I and III. | Wikipedia 'Pauwel's angle', classification table (type II 30-50 degrees) and Clinical Use section (internal fixation recommended for 30-50 degree angles; shear/nonunion rise with angle). | ✓ |
| III | Type III (high/vertical angle) | Vertical fracture line oriented greater than 50 degrees from the horizontal (Pauwel's angle >50 degrees). | Most vertical, least stable pattern; Pauwels recommended valgus osteotomy for inclination angles greater than 50 degrees. | Greatest shear stress at the fracture site and the highest nonunion risk of the three grades. | Wikipedia 'Pauwel's angle', classification table (type III >50 degrees) and Clinical Use section (valgus osteotomy for >50 degrees; highest shear and nonunion). | ✓ |

### Per-category citations
- **I**: Wikipedia contributors. Pauwel's angle (2026) — https://en.wikipedia.org/wiki/Pauwel's_angle · Wikipedia 'Pauwel's angle', classification table (type I <30 degrees) and Clinical Use section ('An increasing angle leads to a more unstable fracture and an increase in the shear stress... higher rates of nonunion').
- **II**: Wikipedia contributors. Pauwel's angle (2026) — https://en.wikipedia.org/wiki/Pauwel's_angle · Wikipedia 'Pauwel's angle', classification table (type II 30-50 degrees) and Clinical Use section (internal fixation recommended for 30-50 degree angles; shear/nonunion rise with angle).
- **III**: Wikipedia contributors. Pauwel's angle (2026) — https://en.wikipedia.org/wiki/Pauwel's_angle · Wikipedia 'Pauwel's angle', classification table (type III >50 degrees) and Clinical Use section (valgus osteotomy for >50 degrees; highest shear and nonunion).

## Cross-references
- _shared boundary_ → [Garden — Garden classification of femoral neck fractures](https://radcommons.laudos.ai/systems/garden.md) — Two femoral neck fracture systems: Pauwels by fracture-line angle (shear/biomechanics), Garden by displacement.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/pauwels · API JSON: https://radcommons.laudos.ai/api/v1/systems/pauwels · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Risser — Risser sign of skeletal maturity

> Grades skeletal maturity from iliac apophysis ossification (US convention).

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** current · **Year:** 1958

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0 | No ossification center is seen in the iliac apophysis; apophyseal ossification has not yet begun. | — | Skeletally most immature with the greatest remaining spinal growth, hence the highest risk of scoliosis curve progression. Peak height velocity and about two-thirds of pubertal growth occur before the first signs of iliac apophysis ossification. | PMC3392381 (Hacquebord & Leopold, CORR 2012), 'The Risser Staging System' (criteria) and 'Purpose' (growth/progression); progression framing corroborated by StatPearls NBK499908. | ✓ |
| 1 | Grade 1 | Ossification of the apophysis up to the first (anterolateral) quarter of the iliac crest, about 25% excursion. | — | Early/prepubertal stage with substantial growth remaining. | PMC3392381, 'The Risser Staging System' (US system divides the apophyseal excursion into quarters, anterolateral to posteromedial); explicit 25% value and prepuberty/early-puberty framing from Wikipedia 'Risser sign' grading list. | ✓ |
| 2 | Grade 2 | Ossification up to the second quarter of the iliac crest, about 50% excursion (progressing anterolateral toward posteromedial). | — | Corresponds to the period before or during the pubertal growth spurt. | PMC3392381, quarters statement; explicit 50% value and growth-spurt framing from Wikipedia 'Risser sign'. | ✓ |
| 3 | Grade 3 | Ossification up to the third quarter of the iliac crest, about 75% excursion. | — | Corresponds to slowing of growth (declining growth velocity). | PMC3392381, quarters statement; explicit 75% value and slowing-of-growth framing from Wikipedia 'Risser sign'. | ✓ |
| 4 | Grade 4 | The apophysis is fully (fourth quarter) ossified across the iliac crest, about 100%, but not yet fused to the ilium. | — | Near-cessation of growth, but not a reliable endpoint: the article warns that trunk growth continues until stage 5 and that stage 4 is not an accurate measure of cessation of curve progression. Skeletal maturity is defined in most studies as Risser 4 or higher in females. | PMC3392381, quarters statement and 'Purpose' (stage 4 not accurate for cessation; growth continues to stage 5); explicit 100% value from Wikipedia 'Risser sign'; female maturity threshold from StatPearls NBK499908. | ✓ |
| 5 | Grade 5 | Complete ossification and fusion of the iliac apophysis to the iliac crest. | — | Skeletal maturity / end of growth; trunk growth completes by this stage. In males, skeletal maturity is defined as Risser 5. | PMC3392381, 'The Risser Staging System' (stage 5 = complete ossification and fusion) and 'Purpose' (trunk growth continues until stage 5); male maturity threshold from StatPearls NBK499908. | ✓ |

### Per-category citations
- **0**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381 (Hacquebord & Leopold, CORR 2012), 'The Risser Staging System' (criteria) and 'Purpose' (growth/progression); progression framing corroborated by StatPearls NBK499908.
- **1**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381, 'The Risser Staging System' (US system divides the apophyseal excursion into quarters, anterolateral to posteromedial); explicit 25% value and prepuberty/early-puberty framing from Wikipedia 'Risser sign' grading list.
- **2**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381, quarters statement; explicit 50% value and growth-spurt framing from Wikipedia 'Risser sign'.
- **3**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381, quarters statement; explicit 75% value and slowing-of-growth framing from Wikipedia 'Risser sign'.
- **4**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381, quarters statement and 'Purpose' (stage 4 not accurate for cessation; growth continues to stage 5); explicit 100% value from Wikipedia 'Risser sign'; female maturity threshold from StatPearls NBK499908.
- **5**: Hacquebord JH, Leopold SS. In Brief: The Risser Classification: A Classic Tool for the Clinician Treating Adolescent Idiopathic Scoliosis (2012) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3392381/ · PMC3392381, 'The Risser Staging System' (stage 5 = complete ossification and fusion) and 'Purpose' (trunk growth continues until stage 5); male maturity threshold from StatPearls NBK499908.

## Cross-references
- _characterizes_ → [Lenke — Lenke 2D classification of operative adolescent idiopathic scoliosis](https://radcommons.laudos.ai/systems/lenke.md) — Risser skeletal maturity informs progression risk and timing in idiopathic scoliosis classified by Lenke.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/risser · API JSON: https://radcommons.laudos.ai/api/v1/systems/risser · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Salter-Harris — Salter-Harris classification of physeal fractures

> Classifies fractures involving the growth plate in skeletally immature patients.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1963 · **Year:** 1963

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Fracture plane runs transversely through the physis (growth plate) only, separating the epiphysis from the metaphysis without involving either bony segment; radiographs may be normal or show only physeal widening/epiphyseal displacement. Accounts for ~5% of cases. SALTR mnemonic: S = Slip (slipped physis). | Generally treated non-operatively with closed reduction and cast or splint immobilization; surgery is rarely needed. | Lowest-risk type: low propensity for growth disturbance and a favorable prognosis when the germinal layer and physeal blood supply are preserved. | Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 ('Salter-Harris I and II fractures can be treated with closed reduction, casting, or splinting'; lower types 'less severe and have less of a propensity for growth abnormalities'). | ✓ |
| II | Type II | Fracture extends through the physis and exits obliquely through the metaphysis, sparing the epiphysis, leaving a triangular metaphyseal fragment (Thurston-Holland fragment / corner sign). Most common type (~75%). SALTR mnemonic: A = Above (line continues above the physis, into the metaphysis). | Usually treated non-operatively with closed reduction and cast/splint immobilization; surgery reserved for unstable or irreducible injuries. | Low risk of growth disturbance with a generally favorable prognosis, similar to type I. | Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic (Thurston-Holland fragment); management and prognosis from StatPearls NBK430688 (closed reduction/casting for types I-II; low propensity for growth abnormality). | ✓ |
| III | Type III | Intra-articular fracture extending through the physis and exiting through the epiphysis, sparing the metaphysis, and crossing the articular surface/cartilage. SALTR mnemonic: L = Lower (fracture below the physis, into the epiphysis). | Often requires open reduction and internal fixation to restore the articular surface, with fixation placed so as not to cross the physis. | Moderate risk: intra-articular and physeal involvement carry a risk of growth retardation, altered joint mechanics, and functional impairment. | Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 ('usually require open reduction and internal fixation (avoiding crossing the physis)'; risk of growth retardation/altered joint mechanics/functional impairment). | ✓ |
| IV | Type IV | Intra-articular fracture passing through all three elements — epiphysis, physis, and metaphysis — in a single line crossing the growth plate, involving the articular surface. SALTR mnemonic: TE = Through Everything. | Surgical: typically requires open reduction and internal fixation to anatomically realign the physis and articular surface. | Higher risk of premature physeal fusion/growth arrest, articular incongruity, and functional impairment; higher Salter-Harris types carry greater risk of growth disturbance. | Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 (ORIF standard; growth retardation/altered joint mechanics; 'higher-grade Salter-Harris fractures have a higher incidence of premature physeal fusion'). | ✓ |
| V | Type V | Crush/compression injury of the physis with no discrete fracture line, damaging the germinal and hypertrophic layers and physeal vascular supply; often radiographically occult, sometimes seen as reduced epiphyseal-metaphyseal distance. Very rare; frequently diagnosed retrospectively. SALTR mnemonic: R = Rammed (crush). | Recognition warrants prompt orthopedic consultation; diagnosis is often delayed and management focuses on monitoring for growth arrest. | Poorest prognosis: high likelihood of growth arrest/premature physeal fusion owing to germinal-matrix and vascular injury. | Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 (crush of germinal matrix and vascular supply, often retrospective diagnosis; 'poor prognosis leading to bone growth arrest'). | ✓ |

### Per-category citations
- **I**: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture · Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 ('Salter-Harris I and II fractures can be treated with closed reduction, casting, or splinting'; lower types 'less severe and have less of a propensity for growth abnormalities').
- **II**: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture · Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic (Thurston-Holland fragment); management and prognosis from StatPearls NBK430688 (closed reduction/casting for types I-II; low propensity for growth abnormality).
- **III**: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture · Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 ('usually require open reduction and internal fixation (avoiding crossing the physis)'; risk of growth retardation/altered joint mechanics/functional impairment).
- **IV**: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture · Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 (ORIF standard; growth retardation/altered joint mechanics; 'higher-grade Salter-Harris fractures have a higher incidence of premature physeal fusion').
- **V**: Salter RB, Harris WR. Injuries involving the epiphyseal plate (1963) — https://en.wikipedia.org/wiki/Salter%E2%80%93Harris_fracture · Wikipedia 'Salter-Harris fracture' Types section + SALTER mnemonic; management and prognosis from StatPearls NBK430688 (crush of germinal matrix and vascular supply, often retrospective diagnosis; 'poor prognosis leading to bone growth arrest').


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/salter-harris · API JSON: https://radcommons.laudos.ai/api/v1/systems/salter-harris · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Sanders — Sanders classification of calcaneal fractures

> Classifies intra-articular calcaneal fractures on coronal CT.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1993 · **Year:** 1993

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures (Sanders) (1993) — https://en.wikipedia.org/wiki/Sanders_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Non-displaced posterior facet fracture, regardless of the number of fracture lines seen on the coronal CT image. | Nondisplaced; managed conservatively (closed treatment, e.g., cast immobilization and protected weight-bearing); operative reduction is not required. | Best prognosis of the four types given the preserved articular alignment, though post-traumatic subtalar arthritis can still occur. | Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment ('Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion'). | ✓ |
| II | Type II | Displaced fracture with one fracture line through the posterior facet (producing two articular fragments) on the coronal CT image at the widest point of the posterior facet. | Displaced intra-articular fracture; typically treated with open reduction and internal fixation (ORIF) to restore the posterior facet, though percutaneous techniques are used in selected cases. | Better long-term outcomes than type III; reported to require subsequent subtalar fusion far less often (type III was about 4x more likely to need eventual fusion than type II). | Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment/Prognosis ('Type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II'). | ✓ |
| III | Type III | Displaced fracture with two fracture lines through the posterior facet (producing three articular fragments, typically including a depressed central fragment) on the coronal CT image. | Displaced/comminuted intra-articular fracture; ORIF is the usual treatment, with patient counseling about the elevated likelihood of later subtalar fusion. | Worse prognosis than type II: about four times more likely to require eventual subtalar fusion; post-traumatic subtalar arthritis is common and recovery is prolonged. | Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Prognosis ('Type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II').; corroborated by PMC9572188 (type III vs IV outcomes). | ✓ |
| IV | Type IV | Comminuted fracture with more than three fracture lines in the posterior facet (four or more articular fragments) on the coronal CT image. | Highly comminuted; managed by ORIF or primary subtalar arthrodesis. Primary fusion is favored by some surgeons because it reduces the need for subsequent procedures. | Worst prognosis with the highest rate of subtalar arthritis and reoperation; higher wound-complication rates than type III, and outcomes converge toward poor with type III on long-term follow-up. | Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment ('Some surgeons will favor primary subtalar arthrodesis as it seems to reduce the need for subsequent procedures'); complication/outcome detail corroborated by PMC9572188. | ✓ |

### Per-category citations
- **I**: Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures (Sanders) (1993) — https://en.wikipedia.org/wiki/Sanders_classification · Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment ('Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion').
- **II**: Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures (Sanders) (1993) — https://en.wikipedia.org/wiki/Sanders_classification · Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment/Prognosis ('Type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II').
- **III**: Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures (Sanders) (1993) — https://en.wikipedia.org/wiki/Sanders_classification · Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Prognosis ('Type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II').; corroborated by PMC9572188 (type III vs IV outcomes).
- **IV**: Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures (Sanders) (1993) — https://en.wikipedia.org/wiki/Sanders_classification · Criteria: Wikipedia 'Sanders classification', Classification section. Management/prognosis: NBK430861 (StatPearls, Calcaneus Fractures), Treatment ('Some surgeons will favor primary subtalar arthrodesis as it seems to reduce the need for subsequent procedures'); complication/outcome detail corroborated by PMC9572188.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/sanders · API JSON: https://radcommons.laudos.ai/api/v1/systems/sanders · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Schatzker — Schatzker classification of tibial plateau fractures

> Classifies tibial plateau fractures by pattern and complexity.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1979 · **Year:** 1979

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, XR
- Primary source: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Lateral tibial plateau fracture without articular depression: a wedge-shaped, pure cleavage (vertical split) of the lateral plateau, typically a low-energy injury in younger patients with good bone quality. | Minimally displaced splits are managed nonoperatively (protected weight-bearing). Operative ORIF is indicated for significant displacement, articular step-off, condylar widening, or instability; lateral depression over ~6 mm or widening over ~5 mm raises concern for associated meniscal/ligament injury that should be addressed. | Lower-energy pattern; soft-tissue injury risk rises with greater depression/widening. Lateral meniscal and ligament tears are associated, particularly as displacement increases. | Wikipedia 'Schatzker classification', Classification subsection (type definition); management and soft-tissue thresholds from StatPearls 'Tibial Plateau Fractures' (NBK470593), Treatment/Complications sections ('articular surface depression of more than 6mm and/or articular widening of more than 5 mm'). | ✓ |
| II | Type II | Lateral tibial plateau fracture combining a cleavage split with depression of the articular surface; the most common type, usually low-energy. | Nonoperative for minimally displaced/depressed fractures; ORIF (often with elevation of the depressed fragment, bone grafting/void filler, and buttress plating) for significant articular step-off, condylar widening, or instability. | Most commonly associated with lateral meniscal tears, especially when articular depression exceeds ~10 mm. | Wikipedia 'Schatzker classification', Classification subsection; management/associations from StatPearls NBK470593, Treatment and Complications sections ('Lateral meniscal tears... most common with Schatzker II... especially with depression >10mm'). | ✓ |
| III | Type III | Focal/pure depression of the lateral (or central) articular surface with no associated split (pure compression); rare; tends to occur in older patients with weaker bone. | Nonoperative if minimally depressed and the joint is stable; ORIF with elevation of the depressed segment and subchondral grafting/void filling when articular depression is significant or the joint is unstable. | Risk of articular incongruity and secondary instability; associated soft-tissue injury is less frequent than in split-depression patterns. | Wikipedia 'Schatzker classification', Classification subsection; management principles from StatPearls NBK470593, Treatment section (nonoperative for minimally displaced split or depression patterns; ORIF for significant step-off). | ✓ |
| IV | Type IV | Medial tibial plateau fracture, with or without depression; may involve the tibial spines. High-energy varus injury often representing a fracture-dislocation. | Generally operative (ORIF); part of the IV/V/VI group for which surgery is recommended. Requires careful neurovascular assessment given the fracture-dislocation mechanism. | Higher rate of neurovascular injury (vascular injury common in IV fracture-dislocations); medial meniscus tears most common in this pattern; ACL injury reported in about a quarter of type IV and VI patterns. | Wikipedia 'Schatzker classification', Classification subsection; risks and operative indication from StatPearls NBK470593, Treatment/Complications ('Schatzker IV, V, and VI injuries' operative; 'ACL injuries... a quarter of Schatzker type IV and VI'; 'Vascular injury... common in Schatzker IV fracture-dislocations'). | ✓ |
| V | Type V | Bicondylar fracture involving split of both the medial and lateral plateaus; high-energy combined varus/valgus mechanism. | Operative (ORIF), frequently with dual plating; staged management with temporary spanning external fixation may be used while soft tissues recover. Part of the IV/V/VI group for which surgery is recommended. | High-energy bicondylar injury carries substantial risk of compartment syndrome and significant soft-tissue compromise. | Wikipedia 'Schatzker classification', Classification subsection; operative indication from StatPearls NBK470593, Treatment section ('Schatzker IV, V, and VI injuries'); compartment syndrome noted as 'a devastating complication'. | ✓ |
| VI | Type VI | Tibial plateau fracture with metaphyseal-diaphyseal dissociation: a transverse subcondylar fracture separating the metaphysis from the diaphysis; high-energy, frequently open. | Operative; commonly staged with temporary spanning external fixation followed by definitive ORIF once soft tissues stabilize. Part of the IV/V/VI group for which surgery is recommended. | High-energy pattern with elevated risk of compartment syndrome, open injury, and neurovascular compromise; ACL injury reported in about a quarter of type IV and VI patterns. | Wikipedia 'Schatzker classification', Classification subsection; operative indication and risks from StatPearls NBK470593, Treatment/Complications ('Schatzker IV, V, and VI injuries' operative; compartment syndrome 'a devastating complication'; ACL injuries in 'a quarter of Schatzker type IV and VI fracture patterns'). | ✓ |

### Per-category citations
- **I**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection (type definition); management and soft-tissue thresholds from StatPearls 'Tibial Plateau Fractures' (NBK470593), Treatment/Complications sections ('articular surface depression of more than 6mm and/or articular widening of more than 5 mm').
- **II**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection; management/associations from StatPearls NBK470593, Treatment and Complications sections ('Lateral meniscal tears... most common with Schatzker II... especially with depression >10mm').
- **III**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection; management principles from StatPearls NBK470593, Treatment section (nonoperative for minimally displaced split or depression patterns; ORIF for significant step-off).
- **IV**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection; risks and operative indication from StatPearls NBK470593, Treatment/Complications ('Schatzker IV, V, and VI injuries' operative; 'ACL injuries... a quarter of Schatzker type IV and VI'; 'Vascular injury... common in Schatzker IV fracture-dislocations').
- **V**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection; operative indication from StatPearls NBK470593, Treatment section ('Schatzker IV, V, and VI injuries'); compartment syndrome noted as 'a devastating complication'.
- **VI**: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture (Schatzker) (1979) — https://en.wikipedia.org/wiki/Schatzker_classification · Wikipedia 'Schatzker classification', Classification subsection; operative indication and risks from StatPearls NBK470593, Treatment/Complications ('Schatzker IV, V, and VI injuries' operative; compartment syndrome 'a devastating complication'; ACL injuries in 'a quarter of Schatzker type IV and VI fracture patterns').


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/schatzker · API JSON: https://radcommons.laudos.ai/api/v1/systems/schatzker · Agent index: https://radcommons.laudos.ai/llms.txt

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# Tile — Tile classification of pelvic ring injuries

> Classifies pelvic ring injuries by stability.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1988 · **Year:** 1988

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, XR
- Primary source: Tile M. Pelvic ring fractures: should they be fixed? (Tile) (1988) — https://en.wikipedia.org/wiki/Tile_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Type A, stable | Stable pelvic ring injury with the posterior sacroiliac complex intact; the ring is both rotationally and vertically stable (e.g. avulsions or minimally displaced ring fractures). | Nonoperative management: stable ring injuries are treated conservatively with protected weight-bearing and analgesia; surgery is generally not required. | Lowest-risk pattern: stable pelvic ring injuries carry lower mortality than unstable ones (stable ~7.9% vs unstable ~11.5% in reported series). | StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management section (Type A = nonoperative) and reported stable vs unstable mortality (~7.9% vs ~11.5%). | ✓ |
| B | Type B, rotationally unstable | Partial disruption of the posterior sacroiliac complex producing a rotationally unstable but vertically stable pelvis (includes open-book/AP and lateral-compression patterns). | Often operative depending on displacement: a pelvic binder/external fixation controls open-book diastasis acutely, and ORIF (e.g. anterior plating/symphyseal fixation) is used for significant rotational instability; minimally displaced patterns may be managed nonoperatively. | Intermediate-risk pattern: rotational instability with potential for significant hemorrhage; open-book (AP-compression) injuries can enlarge pelvic volume and bleed. | StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management (Type B - binder/external fixation/ORIF by displacement) and hemorrhage discussion. | ✓ |
| C | Type C, rotationally and vertically unstable | Complete disruption of the posterior sacroiliac complex producing a pelvis that is both rotationally and vertically unstable (may be unilateral, bilateral, or associated with an acetabular fracture). | Operative management is indicated: resuscitation with a pelvic binder, angiographic embolization or preperitoneal packing for hemodynamic instability, then definitive posterior and anterior fixation (percutaneous SI screws, external fixation, ORIF). | Highest-risk pattern: greatest hemorrhage and mortality among pelvic ring injuries; open unstable fractures approach ~50% mortality, and the pelvic venous plexus is the bleeding source in about 80% of cases. | StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management (Type C operative, embolization/packing) and risk data (open-fracture mortality ~50%, venous plexus source ~80%, unstable mortality ~11.5%). | ✓ |

### Per-category citations
- **A**: Tile M. Pelvic ring fractures: should they be fixed? (Tile) (1988) — https://en.wikipedia.org/wiki/Tile_classification · StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management section (Type A = nonoperative) and reported stable vs unstable mortality (~7.9% vs ~11.5%).
- **B**: Tile M. Pelvic ring fractures: should they be fixed? (Tile) (1988) — https://en.wikipedia.org/wiki/Tile_classification · StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management (Type B - binder/external fixation/ORIF by displacement) and hemorrhage discussion.
- **C**: Tile M. Pelvic ring fractures: should they be fixed? (Tile) (1988) — https://en.wikipedia.org/wiki/Tile_classification · StatPearls 'Pelvic Ring Injuries' NBK544330, Treatment/Management (Type C operative, embolization/packing) and risk data (open-fracture mortality ~50%, venous plexus source ~80%, unstable mortality ~11.5%).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/tile-pelvis · API JSON: https://radcommons.laudos.ai/api/v1/systems/tile-pelvis · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Tönnis — Tönnis grading of hip osteoarthritis

> Grades hip osteoarthritis radiographically.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Orthopedic consensus · **Version:** 1976 · **Year:** 1976

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Tönnis D. Normal values of the hip joint for the evaluation of X-rays (Tönnis) (1976) — https://en.wikipedia.org/wiki/T%C3%B6nnis_classification
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0 | No radiographic signs of osteoarthritis: no subchondral sclerosis, normal joint space, no subchondral cysts, and a normally spherical femoral head. | Favorable for joint-preserving surgery: the literature supports hip preservation (arthroscopy/FAI correction, osteotomy) for Tonnis 0-1 hips, with the most predictable outcomes. | Best prognosis for hip preservation; lowest reported conversion to total hip arthroplasty after arthroscopy. | Tonnis grade definitions from open-access PMC7391593 (binary Tonnis modification), Table 1 (grade 0 = no OA); preservation-for-0/1 principle from the same article ('hip preservation for hips graded Tonnis 0 and 1, replacement for 2 and 3'). | ✓ |
| 1 | Grade 1 | Mild osteoarthritis: increased subchondral sclerosis with minimal joint-space narrowing and early osteophyte formation; the femoral head contour remains essentially normal. | Still suitable for joint-preserving surgery: arthroscopy/FAI surgery in selected patients shows durable improvement, though slightly less reliable than grade 0. | Good prognosis: outcomes after hip preservation are generally predictable in Tonnis 0-1. | Tonnis grade definitions from open-access PMC7391593, Table 1 (grade 1 = sclerosis, minimal JSN, osteophytes); preservation suitability for Tonnis 0-1 from the same article. | ✓ |
| 2 | Grade 2 | Moderate osteoarthritis: small subchondral cyst formation with moderate joint-space narrowing and moderate loss of femoral-head sphericity. | Gray zone: joint preservation/arthroscopy has only a limited, selective role with clinical equipoise; many favor caution because conversion to arthroplasty is markedly more likely. | Worse prognosis than grade 1: Tonnis 2 at baseline carries a significantly higher risk of conversion to total hip arthroplasty (about 3.4-fold relative to Tonnis 1), with 10-year arthroscopy survivorship ~38% vs ~81% for grade 1. | Grade-2 definition from open-access PMC7391593, Table 1 (small cysts, moderate JSN); THA conversion RR 3.44 (95% CI 1.81-6.55) and 10-yr survivorship 38% vs 81% from open-access PMC12205409 (Nikou et al., 10-year hip-arthroscopy outcomes). | ✓ |
| 3 | Grade 3 | Severe (advanced) osteoarthritis: large subchondral cysts, severe joint-space narrowing or obliteration, and severe deformation of the femoral head. | Total hip arthroplasty is the realistic treatment: hip-preservation/arthroscopy is generally not recommended at this stage of advanced degeneration. | Poorest prognosis for preservation: hip-preserving procedures are rarely durable, and arthroplasty is the reliable option. | Grade-3 definition from open-access PMC7391593, Table 1 (large cysts, joint-space obliteration, severe head deformation); replacement-rather-than-preservation for Tonnis 2-3 stated in the same article. | ✓ |

### Per-category citations
- **0**: Tönnis D. Normal values of the hip joint for the evaluation of X-rays (Tönnis) (1976) — https://en.wikipedia.org/wiki/T%C3%B6nnis_classification · Tonnis grade definitions from open-access PMC7391593 (binary Tonnis modification), Table 1 (grade 0 = no OA); preservation-for-0/1 principle from the same article ('hip preservation for hips graded Tonnis 0 and 1, replacement for 2 and 3').
- **1**: Tönnis D. Normal values of the hip joint for the evaluation of X-rays (Tönnis) (1976) — https://en.wikipedia.org/wiki/T%C3%B6nnis_classification · Tonnis grade definitions from open-access PMC7391593, Table 1 (grade 1 = sclerosis, minimal JSN, osteophytes); preservation suitability for Tonnis 0-1 from the same article.
- **2**: Tönnis D. Normal values of the hip joint for the evaluation of X-rays (Tönnis) (1976) — https://en.wikipedia.org/wiki/T%C3%B6nnis_classification · Grade-2 definition from open-access PMC7391593, Table 1 (small cysts, moderate JSN); THA conversion RR 3.44 (95% CI 1.81-6.55) and 10-yr survivorship 38% vs 81% from open-access PMC12205409 (Nikou et al., 10-year hip-arthroscopy outcomes).
- **3**: Tönnis D. Normal values of the hip joint for the evaluation of X-rays (Tönnis) (1976) — https://en.wikipedia.org/wiki/T%C3%B6nnis_classification · Grade-3 definition from open-access PMC7391593, Table 1 (large cysts, joint-space obliteration, severe head deformation); replacement-rather-than-preservation for Tonnis 2-3 stated in the same article.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/tonnis-hip · API JSON: https://radcommons.laudos.ai/api/v1/systems/tonnis-hip · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Weber — Weber (Danis-Weber) classification of fibular ankle fractures

> Per-ankle label determined only by the fibular fracture level relative to the distal tibiofibular syndesmosis: A below, B at and C above. The type does not by itself prove syndesmotic or deltoid integrity, mortise stability, prognosis or need for surgery; report those findings independently.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Weber / ankle-trauma literature · **Version:** Weber 1972 level classification; stability and care context reviewed through 2018 · **Year:** 1972

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, CT
- Primary source: Weber BG. Die Verletzungen des oberen Sprunggelenkes (1972) — https://cir.nii.ac.jp/crid/1130000795807421952
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify fibular fracture level only. Report mortise, medial column, posterior malleolus, syndesmosis, proximal fibula and urgency separately; no Weber type is inherently a treatment order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Weber A, infrasyndesmotic fibular fracture | Weber A: the fibular fracture is below the distal tibiofibular syndesmosis (infrasyndesmotic). Assign the letter from level only; do not encode mortise stability or declare the syndesmosis and deltoid ligament intact without their own evidence. | Assess deformity, open injury, neurovascular status, mortise congruence, medial and posterior malleoli and syndesmotic or proximal-fibular injury independently. A fracture proven stable may follow a functional or nonoperative pathway, but type A alone does not forbid surgery or prove that pathway appropriate. | The distal level is an anatomic descriptor, not a guarantee of stability or a calibrated probability of displacement, nonunion, arthritis or good outcome. Coexisting medial, posterior, osteochondral or ligamentous injury can dominate risk. | Weber 1972 monograph bibliographic record for classification lineage; Lampridis et al., PMC5994620, Danis-Weber level definitions and stability limitations; BOAST 12 standards for assessment, reduction, imaging and stability-based care. | ✓ |
| B | Weber B, transsyndesmotic fibular fracture | Weber B: the fibular fracture crosses or is centered at the level of the distal tibiofibular syndesmosis (transsyndesmotic), often oblique or spiral. The letter alone does not determine deltoid, syndesmotic or mortise integrity. | Establish stability from mortise and medial-column findings, supported weight-bearing radiographs when clinically appropriate, and stress or operative assessment when indicated. Many isolated Weber B fractures are stable and nonoperative; unstable patterns may require fixation, but the letter neither mandates nor excludes surgery. | Type B spans stable and unstable injuries and has no patient-specific complication probability. The same fibular level can coexist with different medial and syndesmotic injuries, so raw findings and stability evidence are more informative than the letter alone. | Lampridis et al., EFORT Open Rev 2018, DOI 10.1302/2058-5241.3.170057, stability diagnosis, weight-bearing radiographs and treatment discussion; Hermans et al., PMC3368108, limited sensitivity of level classification for syndesmotic injury; BOAST 12, uncertain-stability review standard. | ✓ |
| C | Weber C, suprasyndesmotic fibular fracture | Weber C: the fibular fracture is above the distal tibiofibular syndesmosis (suprasyndesmotic). Examine and image the entire fibula when a proximal or Maisonneuve pattern is possible, but do not infer definite syndesmotic widening, deltoid rupture or mortise instability solely from the level. | Urgently reduce a deformed or neurovascularly threatened ankle and assess the mortise, medial column, posterior malleolus and syndesmosis directly. An unstable mortise or syndesmosis may require operative stabilization, yet type C itself does not mandate ORIF, select an implant or define operative levels. | A proximal fibular level is associated with concern for a more extensive injury pattern, but it is an imperfect proxy for actual ligament disruption and carries no calibrated individual probability of instability, arthritis, reoperation or functional loss. | Lampridis et al., PMC5994620, suprasyndesmotic definition and stability limitations; Hermans et al., DOI 10.1007/s00256-011-1284-2, MRI correlation showing level classification does not sensitively exclude syndesmotic injury; BOAST 12, whole-leg imaging, urgent reduction and syndesmotic assessment standards. | ✓ |

### Per-category citations
- **A**: Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5994620/ · Weber 1972 monograph bibliographic record for classification lineage; Lampridis et al., PMC5994620, Danis-Weber level definitions and stability limitations; BOAST 12 standards for assessment, reduction, imaging and stability-based care.
- **B**: Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5994620/ · Lampridis et al., EFORT Open Rev 2018, DOI 10.1302/2058-5241.3.170057, stability diagnosis, weight-bearing radiographs and treatment discussion; Hermans et al., PMC3368108, limited sensitivity of level classification for syndesmotic injury; BOAST 12, uncertain-stability review standard.
- **C**: Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5994620/ · Lampridis et al., PMC5994620, suprasyndesmotic definition and stability limitations; Hermans et al., DOI 10.1007/s00256-011-1284-2, MRI correlation showing level classification does not sensitively exclude syndesmotic injury; BOAST 12, whole-leg imaging, urgent reduction and syndesmotic assessment standards.

## Cross-references
- _shared boundary_ → [Lauge-Hansen — Lauge-Hansen classification of ankle fractures](https://radcommons.laudos.ai/systems/lauge-hansen.md) — Weber assigns A, B or C only from fibular fracture level relative to the syndesmosis. Lauge-Hansen describes inferred mechanism and staged component injuries; no automatic letter-to-mechanism crosswalk is valid.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2018-06-01 | revised | The EFORT stability review emphasized medial-column and mortise stability, weight-bearing assessment and the limitations of treatment decisions based on Weber type alone; this is a use boundary, not a new Weber version. | confirmed |
| 2016-08-01 | revised | BOAST 12 supplied current acute ankle-fracture assessment, imaging and stability-based care standards. It did not revise the A/B/C fibular-level definitions. | confirmed |
| 1972-01-01 | published | Weber published the three-level fibular ankle-fracture framework in Die Verletzungen des oberen Sprunggelenkes. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/weber · API JSON: https://radcommons.laudos.ai/api/v1/systems/weber · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Young-Burgess — Young and Burgess classification of pelvic ring injuries

> Classifies pelvic ring injuries by mechanism.

**Status:** current · **Organ:** Musculoskeletal · **Issuing body:** Radiology consensus · **Version:** 1990 · **Year:** 1990

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, XR
- Primary source: Young JWR, Burgess AR. Pelvic ring disruptions: mechanism of injury classification (Young and Burgess) (1990) — https://www.ncbi.nlm.nih.gov/books/NBK544330/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| LC | Lateral compression | Lateral compression: a side-directed force that internally rotates the hemipelvis, typically producing a transverse/oblique anterior ring fracture with an ipsilateral posterior (sacral) injury; the most common mechanism and generally the more stable pattern (subtypes LC1 anterior sacral compression, LC2 crescent fracture, LC3 contralateral AP injury). | LC1 is typically stable and managed non-operatively; LC2 and LC3 are unstable and generally require fixation. Use caution with pelvic binders, which can over-compress an internally rotated (LC) pelvis and injure other structures. | Generally the more stable, lower-hemorrhage pattern; closed head injury (not pelvic bleeding) is the most common cause of death in LC injuries. Stable patterns carry ~7.9% mortality versus ~11.5% for unstable patterns. | Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (LC1 stable/non-operative, LC2-3 unstable; binder over-compression caution; head injury leading cause of LC mortality; ~7.9% vs ~11.5% mortality stable vs unstable) | ✓ |
| APC | Anteroposterior compression | Anteroposterior compression: a front-to-back force that externally rotates the hemipelvis, opening the symphysis (open-book pattern) with progressive disruption of the sacrospinous, sacrotuberous, and sacroiliac ligaments; associated with hemorrhage (APC1 minor symphysis widening, APC2 >2.5 cm opening with anterior SI ligament disruption, APC3 complete anterior and posterior SI disruption). | APC1 is minimally unstable; APC2 and APC3 are progressively unstable and require fixation. A pelvic binder can help reduce open-book volume acutely; angioembolization is considered for ongoing arterial bleeding. | Higher hemorrhage risk; the superior gluteal artery is most frequently injured in APC patterns. Unstable patterns carry higher mortality (~11.5%) than stable ones (~7.9%). | Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (APC1 minimally unstable, APC2-3 require fixation; superior gluteal artery most affected; ~11.5% mortality unstable vs ~7.9% stable) | ✓ |
| VS | Vertical shear | Vertical shear: an axially directed force producing vertical displacement of the hemipelvis with complete ligamentous disruption, representing complete (rotational and vertical) instability. | Completely unstable; requires operative stabilization, with a pelvic binder considered in the hemodynamically unstable patient for temporary stabilization. | Complete instability with high associated hemorrhage and injury burden; falls in the unstable group with the higher (~11.5%) mortality. | Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (vertical displacement = complete instability, operative management, binder if hemodynamically unstable; unstable-group mortality ~11.5%) | ✓ |
| CM | Combined mechanism | Combined mechanism: any combination of the lateral compression, anteroposterior compression, and vertical shear force patterns. | No distinct treatment pathway; managed according to its component patterns (stability, fixation, and resuscitation needs of the dominant injuries). | Risk reflects the component patterns; unstable combinations align with the higher (~11.5%) mortality of unstable pelvic ring injuries. | Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (combined patterns managed per component; unstable-injury mortality ~11.5%) | ✓ |

### Per-category citations
- **LC**: Young JWR, Burgess AR. Pelvic ring disruptions: mechanism of injury classification (Young and Burgess) (1990) — https://www.ncbi.nlm.nih.gov/books/NBK544330/ · Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (LC1 stable/non-operative, LC2-3 unstable; binder over-compression caution; head injury leading cause of LC mortality; ~7.9% vs ~11.5% mortality stable vs unstable)
- **APC**: Young JWR, Burgess AR. Pelvic ring disruptions: mechanism of injury classification (Young and Burgess) (1990) — https://www.ncbi.nlm.nih.gov/books/NBK544330/ · Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (APC1 minimally unstable, APC2-3 require fixation; superior gluteal artery most affected; ~11.5% mortality unstable vs ~7.9% stable)
- **VS**: Young JWR, Burgess AR. Pelvic ring disruptions: mechanism of injury classification (Young and Burgess) (1990) — https://www.ncbi.nlm.nih.gov/books/NBK544330/ · Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (vertical displacement = complete instability, operative management, binder if hemodynamically unstable; unstable-group mortality ~11.5%)
- **CM**: Young JWR, Burgess AR. Pelvic ring disruptions: mechanism of injury classification (Young and Burgess) (1990) — https://www.ncbi.nlm.nih.gov/books/NBK544330/ · Evaluation > Classification (Young and Burgess classification); Treatment/Prognosis (combined patterns managed per component; unstable-injury mortality ~11.5%)


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/young-burgess · API JSON: https://radcommons.laudos.ai/api/v1/systems/young-burgess · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Ann Arbor — Ann Arbor staging of lymphoma (Cotswolds/Lugano-modified)

> Stages lymphoma by anatomic distribution of nodal and extranodal involvement, with A/B/E/S/X modifiers.

**Status:** current · **Organ:** Oncology · **Issuing body:** Lymphoma staging consensus · **Version:** current · **Year:** 1971

## Provenance and currency
- Family: algorithm
- Logic type: flat
- Modality: CT, PET
- Primary source: Wikipedia contributors. Ann Arbor staging (2026) — https://en.wikipedia.org/wiki/Ann_Arbor_staging
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Stage I | Disease confined to a single lymph node region or lymphoid structure, or a single extranodal site (IE). Modifiers (all stages): A = no B symptoms; B = B symptoms (unexplained fever, drenching night sweats, or >10% body-weight loss); E = limited contiguous extension into one adjacent extranodal site; S = splenic involvement; X = bulky disease (mass >10 cm, or a mediastinal mass exceeding one-third of the internal transverse thoracic diameter). | Early-stage (I-II) favorable disease is treated with combined-modality therapy: a short course of ABVD chemotherapy (e.g. 2 cycles) followed by involved-site/involved-field radiotherapy. | Early stage (I-IIA) carries an excellent prognosis, with roughly 90% 5-year overall survival. | Wikipedia 'Ann Arbor staging', Principal stages (Stage I) + Modifiers (A/B, E, S, X). Management and survival from StatPearls NBK499969, Treatment/Prognosis ('two cycles of ABVD ... followed by ... involved-field radiation therapy'; early stages I-IIA ~90% 5-year overall survival). | ✓ |
| II | Stage II | Involvement of two or more lymph node regions on the same side of the diaphragm (or localized contiguous extranodal extension, IIE). | Early-stage (I-II) disease is treated with combined-modality therapy (ABVD chemotherapy plus involved-site radiotherapy); unfavorable features (bulky/X disease, elevated ESR, extranodal extension) prompt more chemotherapy cycles (4-6) and higher-dose radiation. | Early favorable stage I-IIA disease has roughly 90% 5-year overall survival; unfavorable features worsen the outlook. | Wikipedia 'Ann Arbor staging', Principal stages (Stage II); corroborated by StatPearls NBK499969, Staging ('2 or more lymph node regions on the same side of the diaphragm'). Management/prognosis from NBK499969 Treatment (combined modality; 4-6 cycles for unfavorable features) and Prognosis (~90% early-stage OS). | ✓ |
| III | Stage III | Lymph node regions or lymphoid structures involved on both sides of the diaphragm; may include splenic (S) or limited contiguous extranodal (E) involvement. | Advanced-stage disease is treated mainly with multi-agent chemotherapy (ABVD for most; escalated BEACOPP or Stanford V in selected higher-risk patients per IPS); radiotherapy is generally not beneficial. | Advanced stage carries a less favorable prognosis than early stage; risk is further stratified by the International Prognostic Score. | Wikipedia 'Ann Arbor staging', Principal stages (Stage III); corroborated by StatPearls NBK499969, Staging ('both sides of the diaphragm'). Management from NBK499969 Treatment (advanced-stage chemotherapy 'ABVD for most patients'; 'radiation, in general, is not beneficial'); IPS stratification noted. | ✓ |
| IV | Stage IV | Diffuse or disseminated involvement of one or more extralymphatic (extranodal) organs or tissues (e.g. liver, bone marrow), beyond limited contiguous E-type extension, with or without associated nodal involvement. | Treated as advanced-stage disease with multi-agent chemotherapy (ABVD for most; escalated BEACOPP or Stanford V in selected higher-risk patients); radiotherapy is generally not beneficial. | Most extensive stage with the least favorable outlook; stage IV disease has roughly 60% 5-year overall survival. | Wikipedia 'Ann Arbor staging', Principal stages (Stage IV); corroborated by StatPearls NBK499969, Staging ('extranodal sites beyond those designated as E'). Management/prognosis from NBK499969 Treatment (advanced-stage chemotherapy) and Prognosis ('stage IV disease ... approximately 60%' 5-year OS). | ✓ |

### Per-category citations
- **I**: Wikipedia contributors. Ann Arbor staging (2026) — https://en.wikipedia.org/wiki/Ann_Arbor_staging · Wikipedia 'Ann Arbor staging', Principal stages (Stage I) + Modifiers (A/B, E, S, X). Management and survival from StatPearls NBK499969, Treatment/Prognosis ('two cycles of ABVD ... followed by ... involved-field radiation therapy'; early stages I-IIA ~90% 5-year overall survival).
- **II**: Wikipedia contributors. Ann Arbor staging (2026) — https://en.wikipedia.org/wiki/Ann_Arbor_staging · Wikipedia 'Ann Arbor staging', Principal stages (Stage II); corroborated by StatPearls NBK499969, Staging ('2 or more lymph node regions on the same side of the diaphragm'). Management/prognosis from NBK499969 Treatment (combined modality; 4-6 cycles for unfavorable features) and Prognosis (~90% early-stage OS).
- **III**: Wikipedia contributors. Ann Arbor staging (2026) — https://en.wikipedia.org/wiki/Ann_Arbor_staging · Wikipedia 'Ann Arbor staging', Principal stages (Stage III); corroborated by StatPearls NBK499969, Staging ('both sides of the diaphragm'). Management from NBK499969 Treatment (advanced-stage chemotherapy 'ABVD for most patients'; 'radiation, in general, is not beneficial'); IPS stratification noted.
- **IV**: Wikipedia contributors. Ann Arbor staging (2026) — https://en.wikipedia.org/wiki/Ann_Arbor_staging · Wikipedia 'Ann Arbor staging', Principal stages (Stage IV); corroborated by StatPearls NBK499969, Staging ('extranodal sites beyond those designated as E'). Management/prognosis from NBK499969 Treatment (advanced-stage chemotherapy) and Prognosis ('stage IV disease ... approximately 60%' 5-year OS).

## Cross-references
- _characterizes_ → [Deauville 5PS — Deauville five-point FDG-PET scale for lymphoma](https://radcommons.laudos.ai/systems/deauville.md) — Deauville assesses metabolic response within the Ann Arbor / Lugano staging framework.
- _shared boundary_ → [Lugano — Lugano classification for lymphoma response](https://radcommons.laudos.ai/systems/lugano.md) — The Lugano classification refines Ann Arbor staging and response assessment for lymphoma.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/ann-arbor · API JSON: https://radcommons.laudos.ai/api/v1/systems/ann-arbor · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Choi — Choi CT response criteria for GIST treated with targeted therapy

> Per-timepoint response assessment for GIST on comparable contrast-enhanced CT, combining the sum of target-lesion diameters, target attenuation and progression morphology such as a new nodule within a treated mass.

**Status:** current · **Organ:** Oncology · **Issuing body:** Choi et al. · **Version:** 2007 original; protocol variants must be identified · **Year:** 2007

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, Chen LL, Podoloff DA, Benjamin RS. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated with imatinib mesylate: proposal of new computed tomography response criteria (2007) — https://pubmed.ncbi.nlm.nih.gov/17470865/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Apply the original OR logic, preserve phase and ROI comparability, and search for progression within a responding mass. Identify any modified Choi protocol instead of silently changing the 2007 criteria.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CR | Complete response | Complete response: disappearance of all known lesions with no new lesion. Confirm that previously measurable and nonmeasurable GIST manifestations have resolved on a technically comparable study; a residual treated mass prevents an anatomic Choi CR even if it is entirely hypoattenuating. | Communicate complete imaging response and the comparison date, then defer treatment duration, surgery and surveillance to the multidisciplinary GIST team. CR is not an instruction to stop a tyrosine-kinase inhibitor and does not establish pathologic complete response or cure. | CR is the most favorable imaging category but carries no individual survival, recurrence or resistance probability. The original criteria were derived from a limited single-institution metastatic-GIST cohort and correlated with metabolic response rather than proving eradication of viable tumor. | Choi et al. 2007, J Clin Oncol 25:1753-1759, DOI 10.1200/JCO.2006.07.3049, proposed CT response criteria: CR requires disappearance of all lesions and no new lesions; study Purpose and Methods define the metastatic GIST and imatinib context. | ✓ |
| PR | Partial response by size or attenuation | Partial response: at least a 10% decrease in the sum of target-lesion longest diameters OR at least a 15% decrease in target-lesion CT attenuation, with no new lesion and no obvious progression of nonmeasurable disease. The original Boolean is OR, not AND; measure attenuation on a comparable portal-venous phase with the same ROI method. | Report the size and attenuation branches separately so the treating team can see why PR was assigned. A density-only response can represent genuine TKI effect despite little shrinkage, but the category alone neither fixes treatment duration nor selects resection, dose or next-line therapy. | The original study found the combined CT criteria more sensitive to early metabolic response than size-only RECIST and associated response with time to progression, but PR is not a calibrated patient-specific prognosis. Acquisition or ROI differences can create a false attenuation response. | Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed CT response criteria and CT-FDG-PET correlation: PR is a size decrease of at least 10% OR attenuation decrease of at least 15%, subject to progression exclusions. Kalkmann et al. 2012, PMC3362866, CT measurement technique and attenuation quality safeguards. | ✓ |
| SD | Stable disease | Stable disease: the examination meets none of the CR, PR or PD rules and there is no symptomatic deterioration attributed to tumor progression. Retain actual SLD and attenuation changes, because a near-threshold density change or technically incomparable CT should not be hidden behind the word stable. | Describe whether stability is size-based, attenuation-based or technically limited and continue clinical correlation with adherence, toxicity and treatment interval. SD can represent meaningful disease control during TKI therapy and does not by itself justify stopping or changing treatment. | SD does not mean biological inactivity and supplies no fixed probability of later progression. Small viable intratumoral nodules can be missed if only global diameter and mean attenuation are reviewed, so morphology must remain part of the assessment. | Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed criteria: SD does not meet CR, PR or PD and has no symptomatic deterioration from tumor progression. Kalkmann et al. 2012, PMC3362866, response-assessment pitfalls and nodule-within-a-mass review. | ✓ |
| PD | Progressive disease including nodule within a mass | Progressive disease is present with at least a 10% size increase that does not meet the 15% attenuation-response criterion, any credible new lesion, or a new or enlarging enhancing intratumoral nodule within a treated mass. New-lesion and nodule-within-a-mass findings override otherwise favorable global size or density change. | Promptly flag technically confirmed PD for multidisciplinary oncology review and document the exact trigger, comparison and possible resistant clone. Confirm an equivocal focus and review adherence and mutation context; the imaging code must not autonomously select a different TKI, dose, operation or palliative plan. | PD denotes imaging evidence of progression or focal resistance but does not quantify survival, mutation or treatment-response probability. Size increase alone can be misleading after TKI-related myxoid degeneration, hemorrhage or necrosis, which is why the density exception and morphology overrides are required. | Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed criteria: PD includes a size increase of at least 10% without a qualifying density response, new lesions, or new or enlarging intratumoral nodules. Kalkmann et al. 2012, PMC3362866, Therapy response assessment and pitfalls illustrate nodule within a mass and standardized portal-venous measurement. | ✓ |

### Per-category citations
- **CR**: Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, Chen LL, Podoloff DA, Benjamin RS. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated with imatinib mesylate: proposal of new computed tomography response criteria (2007) — https://pubmed.ncbi.nlm.nih.gov/17470865/ · Choi et al. 2007, J Clin Oncol 25:1753-1759, DOI 10.1200/JCO.2006.07.3049, proposed CT response criteria: CR requires disappearance of all lesions and no new lesions; study Purpose and Methods define the metastatic GIST and imatinib context.
- **PR**: Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, Chen LL, Podoloff DA, Benjamin RS. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated with imatinib mesylate: proposal of new computed tomography response criteria (2007) — https://pubmed.ncbi.nlm.nih.gov/17470865/ · Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed CT response criteria and CT-FDG-PET correlation: PR is a size decrease of at least 10% OR attenuation decrease of at least 15%, subject to progression exclusions. Kalkmann et al. 2012, PMC3362866, CT measurement technique and attenuation quality safeguards.
- **SD**: Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, Chen LL, Podoloff DA, Benjamin RS. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated with imatinib mesylate: proposal of new computed tomography response criteria (2007) — https://pubmed.ncbi.nlm.nih.gov/17470865/ · Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed criteria: SD does not meet CR, PR or PD and has no symptomatic deterioration from tumor progression. Kalkmann et al. 2012, PMC3362866, response-assessment pitfalls and nodule-within-a-mass review.
- **PD**: Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, Chen LL, Podoloff DA, Benjamin RS. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated with imatinib mesylate: proposal of new computed tomography response criteria (2007) — https://pubmed.ncbi.nlm.nih.gov/17470865/ · Choi et al. 2007, DOI 10.1200/JCO.2006.07.3049, proposed criteria: PD includes a size increase of at least 10% without a qualifying density response, new lesions, or new or enlarging intratumoral nodules. Kalkmann et al. 2012, PMC3362866, Therapy response assessment and pitfalls illustrate nodule within a mass and standardized portal-venous measurement.

## Cross-references
- _shared boundary_ → [RECIST 1.1 — Response Evaluation Criteria in Solid Tumours v1.1](https://radcommons.laudos.ai/systems/recist-1-1.md) — Choi adapts RECIST for GIST by adding CT attenuation change, since size-only RECIST underestimates response to imatinib.
- _shared boundary_ → [mRECIST — Modified RECIST for hepatocellular carcinoma](https://radcommons.laudos.ai/systems/mrecist.md) — Both are density/enhancement-aware response criteria adapting RECIST for a specific tumor type (Choi for GIST, mRECIST for HCC).

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2007-05-01 | published | Choi and colleagues proposed CT response criteria combining target-lesion size, attenuation and progression morphology for metastatic GIST treated with imatinib. | confirmed |
| 2007-01-01 | published | Choi response criteria for GIST published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/choi-gist · API JSON: https://radcommons.laudos.ai/api/v1/systems/choi-gist · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Deauville 5PS — Deauville five-point FDG-PET scale for lymphoma

> Lesion-level visual FDG-uptake score relative to mediastinal blood pool and liver: 1 no uptake, 2 at or below mediastinum, 3 above mediastinum but at or below liver, 4 moderately above liver and 5 markedly above liver and/or new lymphoma-consistent sites. X is a nonordinal qualifier for uptake unlikely to be lymphoma. Response requires baseline change, timepoint and patient-level synthesis; a score alone is not progression, a treatment order or an individualized prognosis.

**Status:** current · **Organ:** Oncology · **Issuing body:** International lymphoma imaging consensus · **Version:** 2009 scale; Lugano 2014 and PRoLoG 2023 operationalization; status reviewed 2025 · **Year:** 2009

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: FDG PET/CT
- Primary source: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Score lesions against valid mediastinal and liver references, then synthesize longitudinal response; never equate a bare 4 or 5 with progression or a treatment order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Score 1, no uptake | No abnormal FDG uptake attributable to lymphoma above background. Confirm baseline FDG avidity, technical comparability and that apparently absent uptake is not caused by an unsuitable study. | Within standard Lugano response assessment, score 1 contributes to complete metabolic response. Continue or change therapy only according to the declared lymphoma protocol, response timepoint, clinical state and multidisciplinary review; the numeral itself is not an order. | Score 1 is metabolically negative under the applicable framework but does not guarantee cure or zero residual microscopic disease. It carries no universal patient-level progression-free-survival probability. | Meignan et al. 2009, DOI 10.1080/10428190903040048, five-point definitions; Cheson et al. 2014, DOI 10.1200/JCO.2013.54.8800, PET response table; PRoLoG 2023 for technical application. | ✓ |
| 2 | Score 2, uptake at or below mediastinum | Lesion FDG uptake is at or below the mediastinal blood-pool reference on the same examination, with a technically valid mediastinal reference and uptake attributable to the evaluated lesion. | Score 2 contributes to complete metabolic response under standard Lugano, with or without a residual mass. Any protocol-specific de-escalation or escalation rule must be named and applied separately from the visual score. | Score 2 is within the standard metabolically negative range but is not a calibrated recurrence probability. Outcome meaning still depends on lymphoma subtype, treatment line, timepoint and protocol. | Meignan et al. 2009, original reference-region scale; Cheson et al. 2014, Lugano PET response table; Barrington et al. 2023, PMC9902846, reference-region and response implementation. | ✓ |
| 3 | Score 3, above mediastinum up to liver | Lesion FDG uptake is above mediastinal blood pool but at or below the normal liver reference. Uptake equal to liver remains score 3 rather than score 4. | Standard Lugano treats score 3 as complete metabolic response. A treatment-de-escalation trial may predeclare a stricter cutoff, but the agent must name that protocol and must not silently redefine score 3 as positive. | Score 3 usually lies in the standard complete-response range, yet its trial-specific action and cohort association vary. It is neither universally positive nor a patient-specific relapse estimate. | Meignan et al. 2009, five-point scale; Cheson et al. 2014, standard scores 1-3 CMR; PRoLoG 2023, PMC9902846, protocol and technical clarifications. | ✓ |
| 4 | Score 4, moderately above liver | Lesion FDG uptake is moderately greater than normal liver uptake. Preserve the qualitative comparison, reference validity, lesion identity and change from baseline or nadir. | Score 4 requires longitudinal synthesis: reduced uptake is partial metabolic response, unchanged uptake is no metabolic response, and increased uptake or qualifying new disease can be progressive metabolic disease. At interim versus end of treatment, the same reduced score-4 uptake has different response wording. Do not change treatment from the bare score. | Score 4 is metabolically positive under standard interpretation but does not itself prove viable lymphoma, progression or treatment failure. Confounding inflammation and the full longitudinal pattern determine meaning; no universal outcome percentage applies. | Cheson et al. 2014, DOI 10.1200/JCO.2013.54.8800, Lugano response table distinguishing PMR, no response and PMD; PRoLoG 2023 for technical and longitudinal application. | ✓ |
| 5 | Score 5, markedly above liver or new lesions | Lesion FDG uptake is markedly greater than normal liver and/or there is a new FDG-avid site whose distribution and appearance are consistent with lymphoma. A new focus unlikely to represent lymphoma is qualified X instead of automatically scored as progression. | Like score 4, score 5 must be compared with baseline or nadir and adjudicated for new-site cause before assigning partial response, no response or progression. Correlate an uncertain new focus with anatomy, timing, follow-up or tissue sampling when it would change care; the score does not autonomously select therapy. | Score 5 indicates the strongest visual metabolic abnormality in the current scale but is not histologic confirmation or a calibrated prognosis. A proposed two-times-liver threshold and 5a/5b split remain future clarifications unless an adopted protocol explicitly invokes them. | Meignan et al. 2009, original score 5 and X concepts; Lugano 2014 response table; PRoLoG 2023 operational guidance; Barrington et al. 2025, DOI 10.1002/hon.70103, current standard and proposal boundary. | ✓ |

### Per-category citations
- **1**: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048 · Meignan et al. 2009, DOI 10.1080/10428190903040048, five-point definitions; Cheson et al. 2014, DOI 10.1200/JCO.2013.54.8800, PET response table; PRoLoG 2023 for technical application.
- **2**: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048 · Meignan et al. 2009, original reference-region scale; Cheson et al. 2014, Lugano PET response table; Barrington et al. 2023, PMC9902846, reference-region and response implementation.
- **3**: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048 · Meignan et al. 2009, five-point scale; Cheson et al. 2014, standard scores 1-3 CMR; PRoLoG 2023, PMC9902846, protocol and technical clarifications.
- **4**: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048 · Cheson et al. 2014, DOI 10.1200/JCO.2013.54.8800, Lugano response table distinguishing PMR, no response and PMD; PRoLoG 2023 for technical and longitudinal application.
- **5**: Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on interim-PET scan in lymphoma (Deauville criteria) (2009) — https://doi.org/10.1080/10428190903040048 · Meignan et al. 2009, original score 5 and X concepts; Lugano 2014 response table; PRoLoG 2023 operational guidance; Barrington et al. 2025, DOI 10.1002/hon.70103, current standard and proposal boundary.

## Cross-references
- _characterizes_ → [Lugano — Lugano classification for lymphoma response](https://radcommons.laudos.ai/systems/lugano.md) — Deauville is the lesion-level FDG visual score used inside Lugano metabolic-response synthesis. A bare score 4 or 5 cannot distinguish partial response, no response and progression without baseline change and timepoint.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2025-01-01 | revised | The current-status consensus confirmed Lugano 2014 remains standard and framed proposed score-5 clarifications as future revisions rather than current replacements. | confirmed |
| 2023-01-01 | revised | PRoLoG published operational clarifications for applying Lugano and Deauville consistently; this did not create a new Deauville version. | confirmed |
| 2014-09-01 | revised | Lugano incorporated the Deauville five-point scale into longitudinal lymphoma metabolic-response assessment without changing its lesion-level reference definitions. | confirmed |
| 2009-08-01 | published | The first international Deauville workshop published the five-point visual FDG-uptake scale using mediastinal and liver references. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/deauville · API JSON: https://radcommons.laudos.ai/api/v1/systems/deauville · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lugano — Lugano classification for lymphoma response

> Assesses lymphoma staging and treatment response.

**Status:** current · **Organ:** Oncology · **Issuing body:** Lymphoma imaging consensus · **Version:** 2014 · **Year:** 2014

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: PET, CT
- Primary source: Cheson BD, Fisher RI, Barrington SF, et al.. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma (Lugano) (2014) — https://doi.org/10.1200/JCO.2013.54.8800
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CMR | Complete metabolic response | Complete Metabolic Response: on FDG-PET, a Deauville 5-point score of 1, 2 or 3 (uptake at or below liver) at any residual mass, with no new FDG-avid disease; on CT, target nodes/nodal masses regress to <=1.5 cm in the longest transverse diameter, with no new lesions. | Indicates treatment success / no metabolically active disease; supports completing or de-escalating planned therapy and proceeding to surveillance per protocol. | Favourable response with strong prognostic value: in Hodgkin lymphoma a negative predictive value of ~95-100% (positive predictive value >90%) is reported, and ~80-100% NPV in aggressive non-Hodgkin lymphoma. | PMC4979083 (Cheson et al., 'Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification') Table 3 'Revised Criteria for Response Assessment', Complete Response row (PET 5PS score 1, 2 or 3; CT 'target nodes/nodal masses must regress to <=1.5 cm in LDi'); prognostic NPV/PPV figures from the PET response-assessment text | ✓ |
| PMR | Partial metabolic response | Partial Metabolic Response: on FDG-PET, a Deauville score of 4 or 5 but with reduced uptake compared with baseline (and, at interim, residual masses of any size); on CT, at least a 50% decrease in the sum of the products of perpendicular diameters (SPD) of up to 6 target measurable nodes/extranodal sites, with no new lesions and no progression. | At interim, reduced uptake (5PS 4-5 but lower than baseline) suggests chemo-sensitive disease and supports continuing therapy; at end of treatment, residual metabolically active disease warrants biopsy or a follow-up scan if further treatment is being considered. | Indicates residual disease; end-of-treatment PMR carries less favourable prognosis than CMR and requires confirmation of activity before changing management. | PMC4979083 Table 3 'Revised Criteria for Response Assessment', Partial Response row (PET 5PS score 4-5 with reduced uptake vs baseline; CT '>=50% decrease in SPD of up to 6 target measurable nodes'); management text on interim chemo-sensitivity and end-of-treatment biopsy/follow-up scan from the PET response-assessment text | ✓ |
| SD | No metabolic response | No Metabolic Response / Stable Disease: on FDG-PET, a Deauville score of 4 or 5 with no significant change in uptake from baseline; on CT, a less-than-50% decrease in the SPD of target lesions from baseline, without meeting any criterion for progressive disease. | Lack of meaningful response; prompts reassessment of the treatment strategy, with confirmation of residual disease (biopsy or repeat imaging) before any change as for residual PET-active disease. | Unfavourable response category — disease neither responding adequately nor formally progressing, conferring a poorer prognosis than metabolic response. | PMC4979083 Table 3 'Revised Criteria for Response Assessment', No Response or Stable Disease row (PET 5PS score 4-5 with no significant change from baseline; CT '<50% decrease from baseline in SPD ... no criteria for progressive disease met') | ✓ |
| PMD | Progressive metabolic disease | Progressive Metabolic Disease: on FDG-PET, a Deauville score of 4 or 5 with increased uptake intensity from baseline and/or new FDG-avid foci consistent with lymphoma; on CT, an individual node/lesion that grows (e.g. >=50% increase in SPD from nadir with the required absolute size increase) or the appearance of any new lesion. | Treatment failure; indicates a change of therapy (next-line/salvage regimen), with biopsy of new or progressing FDG-avid sites where confirmation is needed. | Worst response category — active, progressing lymphoma carrying the least favourable prognosis among the response groups. | PMC4979083 Table 3 'Revised Criteria for Response Assessment', Progressive Disease row (PET 5PS score 4-5 with increased intensity from baseline and/or new foci; CT individual node 'Increase by >=50% from PPD nadir' plus absolute size-increase criteria; new lesions) | ✓ |

### Per-category citations
- **CMR**: Cheson BD, Fisher RI, Barrington SF, et al.. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma (Lugano) (2014) — https://doi.org/10.1200/JCO.2013.54.8800 · PMC4979083 (Cheson et al., 'Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification') Table 3 'Revised Criteria for Response Assessment', Complete Response row (PET 5PS score 1, 2 or 3; CT 'target nodes/nodal masses must regress to <=1.5 cm in LDi'); prognostic NPV/PPV figures from the PET response-assessment text
- **PMR**: Cheson BD, Fisher RI, Barrington SF, et al.. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma (Lugano) (2014) — https://doi.org/10.1200/JCO.2013.54.8800 · PMC4979083 Table 3 'Revised Criteria for Response Assessment', Partial Response row (PET 5PS score 4-5 with reduced uptake vs baseline; CT '>=50% decrease in SPD of up to 6 target measurable nodes'); management text on interim chemo-sensitivity and end-of-treatment biopsy/follow-up scan from the PET response-assessment text
- **SD**: Cheson BD, Fisher RI, Barrington SF, et al.. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma (Lugano) (2014) — https://doi.org/10.1200/JCO.2013.54.8800 · PMC4979083 Table 3 'Revised Criteria for Response Assessment', No Response or Stable Disease row (PET 5PS score 4-5 with no significant change from baseline; CT '<50% decrease from baseline in SPD ... no criteria for progressive disease met')
- **PMD**: Cheson BD, Fisher RI, Barrington SF, et al.. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma (Lugano) (2014) — https://doi.org/10.1200/JCO.2013.54.8800 · PMC4979083 Table 3 'Revised Criteria for Response Assessment', Progressive Disease row (PET 5PS score 4-5 with increased intensity from baseline and/or new foci; CT individual node 'Increase by >=50% from PPD nadir' plus absolute size-increase criteria; new lesions)

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2014-09-01 | published | Lugano classification published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lugano · API JSON: https://radcommons.laudos.ai/api/v1/systems/lugano · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# PERCIST — PERCIST 1.0 metabolic response criteria for solid tumors

> Patient-level FDG PET response using protocol-comparable SULpeak measurements of the hottest evaluable tumor plus whole-study review for new or unequivocally progressive disease.

**Status:** current · **Organ:** Oncology · **Issuing body:** Wahl et al. / nuclear medicine consensus · **Version:** 1.0 (2009; practical clarification 2016) · **Year:** 2009

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: PET, CT
- Primary source: Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria (2009) — https://doi.org/10.2967/jnumed.108.057307
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Run the technical gate before the response thresholds. Keep pretreatment-baseline PERCIST 1.0 separate from nadir, immune and multi-lesion variants, and always pair the hottest-lesion calculation with whole-study review.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CMR | Complete metabolic response | Complete metabolic response: abnormal FDG uptake resolves in every known tumor focus to a level below mean liver activity and indistinguishable from surrounding background blood-pool activity, with no new cancer-typical FDG-avid lesion. SULpeak need not become zero, and a residual anatomic mass can remain; the whole examination, not only the hottest focus, must support complete response. | Report CMR with the baseline and follow-up dates, acquisition comparability, residual morphology and any uncertainty, then defer treatment continuation, cessation and surveillance to the disease-specific multidisciplinary team. CMR is an imaging response state, not proof of pathologic eradication or an instruction to stop therapy. | CMR is the most favorable PERCIST metabolic category but supplies no individualized probability of cure, recurrence or survival. Small-volume viable disease may remain below PET resolution, and inflammation, glucose, uptake time or reconstruction differences can alter apparent activity. | Wahl et al. 2009, J Nucl Med 50 Suppl 1:122S-150S, DOI 10.2967/jnumed.108.057307, PMC2755245, proposed PERCIST 1.0 response definitions; O et al. 2016, Radiology 280:576-584, DOI 10.1148/radiol.2016142043, PMC4976461, Response Assessment and Practical PERCIST framework clarify background-level resolution, whole-study review and residual-mass interpretation. | ✓ |
| PMR | Partial metabolic response | Partial metabolic response: on technically comparable studies, the SULpeak of the single hottest evaluable malignant focus decreases by at least 30% and by at least 0.8 SUL units relative to the declared pretreatment baseline, with no credible new lesion, no unequivocal progression elsewhere and no disqualifying target-size increase. Both quantitative thresholds are required; the hottest focus at follow-up may be a different lesion. | Return the baseline and follow-up hottest-lesion identities, SULpeak values, relative and absolute changes, interval from treatment and full-study progression review. Use the result as one response input; the API must not infer a drug choice, treatment duration, dose change or operation from PMR alone. | PMR denotes a qualifying fall in FDG avidity but is not a calibrated patient-specific prognosis and does not exclude resistant or discordantly progressing clones. A result can be falsely favorable when the wrong reference scan, SUVmax, a noncomparable acquisition or only one lesion is reviewed. | Wahl et al. 2009, PMC2755245, PERCIST 1.0 quantitative response proposal; O et al. 2016, PMC4976461, Response Assessment, Measurement of Tumor SULpeak and Summary specify at least 30% plus 0.8-SUL decline, the hottest-lesion method, pretreatment reference and progression exclusions. | ✓ |
| SMD | Stable metabolic disease | Stable metabolic disease: the examination is quantitatively assessable and, after review of target, nontarget and new-lesion findings, meets none of CMR, PMR or PMD. Do not reduce SMD to a less-than-30% change shortcut: a new lesion, unequivocal discordant progression, complete resolution or a failed technical gate changes the result. | Report the continuous SULpeak change and technical quality rather than only the word stable, and distinguish biological stability from an indeterminate or noncomparable study. Clinical management remains dependent on tumor type, therapy, symptoms, toxicity, other imaging and protocol-defined endpoints. | SMD does not mean absence of viable tumor, lack of therapeutic benefit or inevitable failure, and it carries no universal survival estimate. Near-threshold measurement variability and mixed lesion behavior can be clinically important despite an unchanged category. | Wahl et al. 2009, PMC2755245, proposed four-category PERCIST synthesis; O et al. 2016, PMC4976461, Response Assessment and Summary define SMD residually after excluding complete response, partial response and progression and emphasize whole-body review and technical comparability. | ✓ |
| PMD | Progressive metabolic disease | Progressive metabolic disease: on comparable studies, the hottest malignant SULpeak increases by at least 30% and by at least 0.8 SUL units, or there is a credible new cancer-typical FDG-avid lesion, unequivocal increase in metabolic extent or qualifying discordant progression. Confirm a small or atypical new focus when inflammation, treatment effect or physiologic uptake is plausible, and record the mechanism that established PMD. | Flag technically supported PMD promptly with the responsible lesion, quantitative change, comparison date and confidence for oncology review. The response code must not autonomously stop or switch treatment; an equivocal new focus should retain an explicit confirmation plan rather than be forced into progression. | PMD indicates imaging evidence of progression but does not quantify survival, resistance mechanism or treatment benefit for an individual. Infection, granulomatous inflammation, immune effects, altered uptake time and partial-volume noise can mimic progression, whereas single-focus measurement can miss heterogeneous response. | Wahl et al. 2009, PMC2755245, PERCIST 1.0 PMD definition and whole-body disease assessment; O et al. 2016, PMC4976461, Response Assessment and Practical PERCIST framework specify the relative and absolute SULpeak increase, new-lesion and extent branches, and careful adjudication of equivocal foci. | ✓ |

### Per-category citations
- **CMR**: Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria (2009) — https://doi.org/10.2967/jnumed.108.057307 · Wahl et al. 2009, J Nucl Med 50 Suppl 1:122S-150S, DOI 10.2967/jnumed.108.057307, PMC2755245, proposed PERCIST 1.0 response definitions; O et al. 2016, Radiology 280:576-584, DOI 10.1148/radiol.2016142043, PMC4976461, Response Assessment and Practical PERCIST framework clarify background-level resolution, whole-study review and residual-mass interpretation.
- **PMR**: Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria (2009) — https://doi.org/10.2967/jnumed.108.057307 · Wahl et al. 2009, PMC2755245, PERCIST 1.0 quantitative response proposal; O et al. 2016, PMC4976461, Response Assessment, Measurement of Tumor SULpeak and Summary specify at least 30% plus 0.8-SUL decline, the hottest-lesion method, pretreatment reference and progression exclusions.
- **SMD**: Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria (2009) — https://doi.org/10.2967/jnumed.108.057307 · Wahl et al. 2009, PMC2755245, proposed four-category PERCIST synthesis; O et al. 2016, PMC4976461, Response Assessment and Summary define SMD residually after excluding complete response, partial response and progression and emphasize whole-body review and technical comparability.
- **PMD**: Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria (2009) — https://doi.org/10.2967/jnumed.108.057307 · Wahl et al. 2009, PMC2755245, PERCIST 1.0 PMD definition and whole-body disease assessment; O et al. 2016, PMC4976461, Response Assessment and Practical PERCIST framework specify the relative and absolute SULpeak increase, new-lesion and extent branches, and careful adjudication of equivocal foci.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2016-08-01 | revised | Practical PERCIST clarified acquisition comparability, target selection, response synthesis and equivocal progression without creating a new numbered version. | confirmed |
| 2009-05-01 | published | PERCIST 1.0 introduced a protocol-controlled SULpeak framework for FDG PET response assessment. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/percist · API JSON: https://radcommons.laudos.ai/api/v1/systems/percist · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# RANO 2.0 — RANO 2.0 response criteria for adult gliomas

> Adult glioma response framework integrating standardized MRI, bidimensional or prespecified volumetric tumor burden, enhancement phenotype, corticosteroid dose, clinical status and confirmation rules for pseudoprogression.

**Status:** current · **Organ:** Oncology · **Issuing body:** Response Assessment in Neuro-Oncology Working Group · **Version:** 2.0 · **Year:** 2023

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use RANO 2.0 as the current adult-glioma framework, preserve the correct baseline and phenotype branch, and never collapse preliminary progression, confirmed progression and pseudoprogression into one undifferentiated PD label.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CR | Complete response | RANO 2.0 complete response: all measurable target disease disappears, relevant nonmeasurable and nontarget disease resolves or remains nonprogressive as the applicable phenotype requires, no new lesion is present, corticosteroid exposure meets the protocol response condition, and the patient is clinically stable or improved. The radiographic response must persist for at least 4 weeks to be confirmed; an earlier CR is preliminary. | Report the target phenotype, baseline, 2D or 3D method, steroid dose, neurological status and confirmation state. CR does not prove cure or permit the API to stop antitumor or corticosteroid therapy; management remains with the neuro-oncology team and trial protocol. | CR is the most favorable RANO 2.0 response state but supplies no individualized survival or recurrence probability. Microscopic infiltrative tumor, treatment-related change and steroid effects can remain despite disappearance of measurable disease. | Wen et al. 2023, J Clin Oncol 41:5187-5199, DOI 10.1200/JCO.23.01059, PMC10860967, Tables 1-3 and sections Response Criteria, Confirmation of Response and Corticosteroid Use define complete response across enhancing, nonenhancing and mixed disease, the 4-week confirmation rule, new-lesion exclusion and clinical/steroid requirements. | ✓ |
| PR | Partial response | RANO 2.0 partial response: at least a 50% decrease in the 2D sum of products of perpendicular diameters or at least a 65% decrease in prespecified 3D tumor volume relative to baseline, with no qualifying progression in the other disease component, no new lesion, acceptable corticosteroid use and clinically stable or improved status. Sustain the response for at least 4 weeks to confirm it; do not mix 2D and 3D methods longitudinally. | Return the exact target set, baseline and current burden, percent change, disease phenotype, steroid and clinical states, and whether the response is preliminary or confirmed. PR is a standardized response observation, not an autonomous instruction to continue a regimen, taper steroids or change surgery or radiotherapy plans. | PR denotes substantial radiographic reduction but is not a patient-specific prognosis and does not exclude viable infiltrative tumor. Antiangiogenic therapy, corticosteroids and permeability change can reduce enhancement without equivalent cytoreduction, while acquisition differences can create false threshold crossing. | Wen et al. 2023, PMC10860967, Tables 1-3 and sections Determination of Radiographic Response and Confirmation of Response specify the at-least-50% 2D or at-least-65% volumetric reduction from baseline, complementary-component, new-lesion, steroid, clinical and 4-week requirements. | ✓ |
| MR | Minor response for nonenhancing disease | RANO 2.0 minor response applies only to protocols evaluating nonenhancing disease: a 2D decrease from 25% through less than 50%, or a prespecified volumetric decrease from 40% through less than 65%, relative to baseline, sustained for at least 4 weeks, with the enhancing component at least stable, no new lesion and no other progression trigger. Do not use MR for enhancing-only disease. | Identify MR explicitly as the RANO 2.0 nonenhancing-disease category and provide both the continuous change and confirmation state. Its presence may be relevant to trial benefit assessment, but it does not select therapy or authorize an autonomous treatment decision. | MR captures a smaller nonenhancing-burden reduction than PR and has no universal individualized prognostic probability. T2/FLAIR change is vulnerable to edema, seizures, ischemia, radiation effect, steroid change and acquisition differences, so causal attribution and technical comparability remain essential. | Wen et al. 2023, PMC10860967, Tables 2-3 and sections Evaluation of Nonenhancing Progression and Determination of Radiographic Response introduce MR for nonenhancing disease with 25% to below 50% 2D or 40% to below 65% volumetric reduction, plus confirmation and complementary-component safeguards. | ✓ |
| SD | Stable disease | Stable disease: an evaluable examination does not meet CR, PR, MR when applicable, or PD, while nontarget disease, neurological status and corticosteroid conditions do not establish progression. When only nonmeasurable disease is present at baseline, SD is the best radiographic response available under RANO 2.0; do not invent a measurable response. | Report actual target and nontarget change, phenotype, steroids, neurological status and technical limitations instead of using stable as a synonym for unchanged biology. Treatment decisions require longitudinal clinical, molecular and protocol context and are outside the category alone. | SD can represent treatment benefit, indolent disease, measurement noise or mixed treatment and tumor effects; it does not provide a universal progression or survival estimate. Nonenhancing progression can be missed if only contrast enhancement is reviewed in a context where T2/FLAIR assessment remains required. | Wen et al. 2023, PMC10860967, Tables 1-3 and sections Measurable Disease and Determination of Radiographic Response define SD residually and state that SD is the best response for patients without measurable disease at baseline. | ✓ |
| PD | Progressive disease | Progressive disease is established by at least a 25% increase in 2D SPD or at least a 40% increase in prespecified 3D volume from the smallest prior valid burden, a credible new measurable lesion, definite leptomeningeal disease, unequivocal qualifying nontarget or nonmeasurable progression, tumor-attributed clinical deterioration or disease-related inability to return. A corticosteroid increase alone is not PD. Suspected enhancing progression within 12 weeks after radiotherapy is preliminary unless histopathology or protocol-defined imaging confirmation establishes true progression. | Promptly communicate the exact PD mechanism, phenotype, comparison and confidence, and arrange protocol or multidisciplinary adjudication when pseudoprogression or another cause is plausible. Within the early post-radiotherapy window, preserve preliminary PD and obtain the required follow-up rather than allowing the API to stop or switch therapy by itself. | PD indicates qualifying radiographic or clinical progression but does not quantify survival or prove treatment resistance. Pseudoprogression, radiation injury, ischemia, seizure, infection, steroid change and antiangiogenic permeability effects can mimic or conceal tumor progression. | Wen et al. 2023, PMC10860967, Tables 1-3 and sections Determination of Progression, Confirmation of Progression, Evaluation in Newly Diagnosed Glioblastoma and Corticosteroid Use specify the at-least-25% 2D or at-least-40% volume increase from nadir, alternative progression triggers, steroid safeguard and early post-radiotherapy confirmation/backdating framework. | ✓ |

### Per-category citations
- **CR**: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/ · Wen et al. 2023, J Clin Oncol 41:5187-5199, DOI 10.1200/JCO.23.01059, PMC10860967, Tables 1-3 and sections Response Criteria, Confirmation of Response and Corticosteroid Use define complete response across enhancing, nonenhancing and mixed disease, the 4-week confirmation rule, new-lesion exclusion and clinical/steroid requirements.
- **PR**: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/ · Wen et al. 2023, PMC10860967, Tables 1-3 and sections Determination of Radiographic Response and Confirmation of Response specify the at-least-50% 2D or at-least-65% volumetric reduction from baseline, complementary-component, new-lesion, steroid, clinical and 4-week requirements.
- **MR**: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/ · Wen et al. 2023, PMC10860967, Tables 2-3 and sections Evaluation of Nonenhancing Progression and Determination of Radiographic Response introduce MR for nonenhancing disease with 25% to below 50% 2D or 40% to below 65% volumetric reduction, plus confirmation and complementary-component safeguards.
- **SD**: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/ · Wen et al. 2023, PMC10860967, Tables 1-3 and sections Measurable Disease and Determination of Radiographic Response define SD residually and state that SD is the best response for patients without measurable disease at baseline.
- **PD**: Wen PY, van den Bent M, Youssef G, et al.. RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10860967/ · Wen et al. 2023, PMC10860967, Tables 1-3 and sections Determination of Progression, Confirmation of Progression, Evaluation in Newly Diagnosed Glioblastoma and Corticosteroid Use specify the at-least-25% 2D or at-least-40% volume increase from nadir, alternative progression triggers, steroid safeguard and early post-radiotherapy confirmation/backdating framework.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2023-09-29 | revised | RANO 2.0 unified adult high- and low-grade glioma response, changed the newly diagnosed post-radiotherapy baseline, added optional volumetry and formalized confirmation rules. | confirmed |
| 2010-03-15 | published | RANO-HGG integrated enhancing burden, T2/FLAIR, corticosteroids and clinical status for high-grade glioma response. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/rano · API JSON: https://radcommons.laudos.ai/api/v1/systems/rano · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# RECIST 1.1 — Response Evaluation Criteria in Solid Tumours v1.1

> Patient-level anatomic response assessment using a fixed target-lesion set, unidimensional diameter sums, qualitative non-target review and explicit new-lesion and evaluability rules.

**Status:** current · **Organ:** Oncology · **Issuing body:** RECIST Working Group · **Version:** 1.1 (2009; committee clarifications current) · **Year:** 2009

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Eisenhauer EA, Therasse P, Bogaerts J, et al.. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) (2009) — https://doi.org/10.1016/j.ejca.2008.10.026
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Keep the fixed target set and the correct baseline-versus-nadir references. Synthesize target, nontarget, new-lesion and evaluability states before returning a patient-level category, and retain any confirmation requirement.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CR | Complete response | Complete response: all target lesions disappear and every pathologic target or nontarget lymph node regresses to a short axis below 10 mm. Overall CR also requires disappearance of nontarget disease, any protocol-required tumor-marker normalization and no new lesion. Nodes are recorded at their actual short axis, so an overall target sum can remain above zero despite valid nodal CR. | Document target, nontarget and new-lesion synthesis, the confirmation requirement for the trial design and any residual nonmalignant morphology. RECIST CR is a trial response endpoint, not proof of cure or an autonomous instruction to stop therapy or surveillance. | CR is the most favorable RECIST 1.1 anatomic category but does not provide an individual probability of pathologic complete response, recurrence or survival. Microscopic disease and viable tumor below spatial resolution can remain. | Eisenhauer et al. 2009, Eur J Cancer 45:228-247, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.5 and Tables 1-2 define target, nontarget and overall CR and the below-10-mm nodal condition; Schwartz et al. 2016, PMC5737828, sections Lymph Nodes and Best Overall Response clarify actual short-axis recording and response synthesis. | ✓ |
| PR | Partial response | Partial response: the target-lesion sum of nonnodal longest axes plus nodal short axes decreases by at least 30% from the baseline sum, with no unequivocal nontarget progression and no new lesion. Target CR with persistent non-CR/non-PD nontarget disease yields overall PR. Under committee clarification, after PR is established a later nonprogressive assessment remains PR rather than requiring the sum to retain a 30% baseline reduction at every visit. | Return the fixed target set, baseline and current sums, percent change, nontarget state, new-lesion review and any protocol-required confirmation. PR standardizes response reporting but must not independently determine treatment duration, dose, operation or next-line therapy. | PR denotes substantial diameter reduction but is not a calibrated survival or cure estimate and does not exclude viable tumor or resistant nontarget disease. Choice of irregular targets, inconsistent technique and threshold-level measurement error can change the category. | Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.5 and Tables 1-2 define at least 30% target-sum decrease from baseline and overall synthesis; Schwartz et al. 2016, PMC5737828, Best Overall Response clarifies longitudinal response after an initial PR and confirmation requirements. | ✓ |
| SD | Stable disease | Stable disease: the target sum has insufficient shrinkage from baseline for PR and insufficient increase from the smallest on-study sum for PD, while nontarget disease has no unequivocal progression and no new lesion is present. Preserve the dual references and the minimum protocol interval; SD is not simply change below 30% from the previous scan. | Report baseline, current and nadir sums with actual change, follow-up interval, nontarget status and technical evaluability. SD can be clinically meaningful disease control but neither mandates continued therapy nor excludes the need for another disease-specific assessment. | SD combines biologically different trajectories and has no universal individual prognosis. Near-threshold error, mixed lesion behavior or non-size biological change can be obscured if only the category is returned. | Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, section 4.3.1 and Table 1 define SD as neither sufficient shrinkage for PR nor sufficient increase for PD using the appropriate baseline and smallest-sum references; Schwartz et al. 2016, PMC5737828, Best Overall Response and Target Lesions address longitudinal application and evaluability. | ✓ |
| PD | Progressive disease | Progressive disease is established by at least a 20% increase in the target sum from the smallest valid on-study sum and an absolute increase of at least 5 mm, or by one or more unequivocally new malignant lesions or substantial unequivocal progression of nontarget disease. Both target-sum thresholds are required. A new lesion need not be measurable; follow an equivocal focus and backdate PD if it is later confirmed. | Flag PD with its exact trigger, responsible lesions, comparison date and confidence for oncology or protocol review. Do not let the API autonomously stop treatment; adjudicate an equivocal new focus, technique change, healing flare or modest isolated nontarget increase before finalizing progression. | PD is a standardized progression endpoint but does not quantify survival, resistance mechanism or treatment benefit for an individual. Inflammation, treatment effect, different coverage, measurement noise and newly visible rather than truly new disease can produce false progression. | Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.4, Table 1 and Appendix II define the paired at-least-20% and at-least-5-mm target rule, unequivocal nontarget progression and new-lesion branch; Schwartz et al. 2016, PMC5737828, sections New Lesions, Non-target Lesions and Target Lesions clarify equivocal follow-up, backdating and substantial overall worsening. | ✓ |

### Per-category citations
- **CR**: Eisenhauer EA, Therasse P, Bogaerts J, et al.. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) (2009) — https://doi.org/10.1016/j.ejca.2008.10.026 · Eisenhauer et al. 2009, Eur J Cancer 45:228-247, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.5 and Tables 1-2 define target, nontarget and overall CR and the below-10-mm nodal condition; Schwartz et al. 2016, PMC5737828, sections Lymph Nodes and Best Overall Response clarify actual short-axis recording and response synthesis.
- **PR**: Eisenhauer EA, Therasse P, Bogaerts J, et al.. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) (2009) — https://doi.org/10.1016/j.ejca.2008.10.026 · Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.5 and Tables 1-2 define at least 30% target-sum decrease from baseline and overall synthesis; Schwartz et al. 2016, PMC5737828, Best Overall Response clarifies longitudinal response after an initial PR and confirmation requirements.
- **SD**: Eisenhauer EA, Therasse P, Bogaerts J, et al.. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) (2009) — https://doi.org/10.1016/j.ejca.2008.10.026 · Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, section 4.3.1 and Table 1 define SD as neither sufficient shrinkage for PR nor sufficient increase for PD using the appropriate baseline and smallest-sum references; Schwartz et al. 2016, PMC5737828, Best Overall Response and Target Lesions address longitudinal application and evaluability.
- **PD**: Eisenhauer EA, Therasse P, Bogaerts J, et al.. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) (2009) — https://doi.org/10.1016/j.ejca.2008.10.026 · Eisenhauer et al. 2009, DOI 10.1016/j.ejca.2008.10.026, sections 4.3-4.4, Table 1 and Appendix II define the paired at-least-20% and at-least-5-mm target rule, unequivocal nontarget progression and new-lesion branch; Schwartz et al. 2016, PMC5737828, sections New Lesions, Non-target Lesions and Target Lesions clarify equivocal follow-up, backdating and substantial overall worsening.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2016-06-01 | revised | The RECIST Committee published implementation clarifications covering measurability, target follow-up, progression, new lesions and confirmation without replacing RECIST 1.1. | confirmed |
| 2009-01-01 | revised | RECIST 1.1 revised guideline published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/recist-1-1 · API JSON: https://radcommons.laudos.ai/api/v1/systems/recist-1-1 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# iRECIST — iRECIST for immunotherapy-trial response data

> Protocol-defined patient-level response data framework for immunotherapy trials. It starts from RECIST 1.1, separates new-lesion burden, and introduces unconfirmed and confirmed progression states. It is not a validated bedside response criterion, a diagnosis of pseudoprogression or an autonomous instruction to continue or stop treatment.

**Status:** current · **Organ:** Oncology · **Issuing body:** RECIST Working Group · **Version:** 2017 guideline; RECIST Working Group clarifications current through 2026 · **Year:** 2017

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Run iRECIST as a longitudinal state machine over RECIST 1.1 component data. Keep trial response assignment, clinical stability, protocol action and prognosis as separate outputs.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| iCR | Immune complete response | At this evaluable protocol timepoint, all target lesions, all non-target disease and all separately tracked new lesions have disappeared, with every lymph node below 10 mm short axis and no progression override. The longitudinal record must retain the fixed baseline target set and every prior immune-response state. | Record iCR as the trial time-point response and apply any protocol-required response confirmation and scheduled imaging. It does not independently justify stopping immunotherapy, changing dose or declaring cure; clinical management remains protocol- and patient-specific. | iCR is an imaging response state, not proof of eradication and not a universal recurrence, survival or durable-benefit probability. Its prognostic meaning depends on tumor type, therapy, assessment schedule, response durability and the trial analysis plan. | Seymour et al. 2017, PMC5648544, Table 1 (iCR and lymph-node rule), Table 2 and time-point response text; Persigehl et al. 2020, PMC6942293, section Responses to therapy. | ✓ |
| iPR | Immune partial response | The target-lesion sum has decreased by at least 30% from baseline after synthesis of target, non-target and separately tracked new-lesion compartments, without an iUPD or iCPD override. A prior unconfirmed progression does not prevent later iPR when progression is not confirmed and the complete state rules are met. | Record iPR and continue protocol-defined assessment; do not convert the category into an autonomous instruction to continue, de-escalate or stop therapy. Preserve the baseline sum, current sum, percent change, non-target state, new-lesion state and any earlier iUPD. | iPR does not supply an individual probability of survival, durable response or later progression. Apparent shrinkage after iUPD can reset the confirmation bar but does not retrospectively prove that the earlier finding was pseudoprogression. | Seymour et al. 2017, PMC5648544, Tables 1-3 and text on time-point response after iUPD; official RECIST Working Group iRECIST FAQ, post-iUPD iPR scenarios and reset logic, reviewed 2026-07-24. | ✓ |
| iSD | Immune stable disease | The evaluable timepoint meets neither iCR nor iPR and has no qualifying progression. After a prior iUPD, a later state may become iSD if progression is not confirmed and the component findings meet stable-disease rules; if findings are simply unchanged at the progression level without a reset state, retain iUPD. | Record iSD with the component measurements and continue the protocol-defined schedule. Stable disease is not synonymous with clinical stability, treatment benefit or absence of biologic progression, and it does not by itself choose therapy. | iSD is a heterogeneous response category with no universal prognosis. Duration, tumor biology, therapy and clinical course matter; never translate it into a fixed progression, survival or benefit estimate without cohort-specific evidence. | Seymour et al. 2017, PMC5648544, Table 1 and time-point response rules; Persigehl et al. 2020, PMC6942293, Responses to therapy; official iRECIST FAQ on unchanged findings versus post-iUPD response. | ✓ |
| iUPD | Immune unconfirmed progression | This is the first unconfirmed progression state: the fixed target sum has increased at least 20% from nadir and at least 5 mm absolutely, existing non-target disease has progressed unequivocally, or one or more new lesions have appeared. New lesions are tracked in separate target and non-target compartments and are not added to the baseline target sum. | If and only if the participant is clinically stable and the protocol/investigator permits treatment beyond progression, treatment may continue while imaging is repeated in 4-8 weeks. Clinical stability requires no performance-status worsening, no clinically relevant increase in disease-related symptoms and no need for intensified palliation. Clinical deterioration can require action without waiting for imaging confirmation. | iUPD is neither confirmed progression nor a diagnosis of pseudoprogression. The category supplies no probability that progression will confirm, no survival estimate and no assurance that waiting is safe; the protocol, symptoms and complete clinical state govern urgency. | Seymour et al. 2017, PMC5648544, Tables 1-3, New lesions and Continued treatment after iUPD sections; official RECIST Working Group iRECIST FAQ, 4-8-week timing and clinical-stability implementation reviewed 2026-07-24. | ✓ |
| iCPD | Immune confirmed progression | After a prior iUPD, the next evaluable assessment confirms additional progression through at least 5 mm further target-sum growth, any further non-target increase, at least 5 mm cumulative new-target-sum growth, any new-non-target increase, an additional new lesion, or qualifying progression in another disease compartment. The confirming event may differ from the compartment that triggered iUPD. | Record iCPD and backdate the immune progression event to the initial iUPD date when the prespecified analysis requires it. iCPD is a confirmed trial response state, not an automatic stop command: treatment decisions still follow the protocol, clinical assessment, participant preferences and investigator judgment. | iCPD supports confirmed radiologic progression within the iRECIST data framework but does not itself quantify survival, treatment resistance or immediate clinical danger. Prognosis and action require tumor-, therapy-, burden-, site- and patient-specific context. | Seymour et al. 2017, PMC5648544, Table 2 and confirmation/analysis sections; official RECIST Working Group iRECIST FAQ on target, non-target, new-lesion, cross-compartment, sequential-increment and event-date rules, reviewed 2026-07-24. | ✓ |

### Per-category citations
- **iCR**: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/ · Seymour et al. 2017, PMC5648544, Table 1 (iCR and lymph-node rule), Table 2 and time-point response text; Persigehl et al. 2020, PMC6942293, section Responses to therapy.
- **iPR**: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/ · Seymour et al. 2017, PMC5648544, Tables 1-3 and text on time-point response after iUPD; official RECIST Working Group iRECIST FAQ, post-iUPD iPR scenarios and reset logic, reviewed 2026-07-24.
- **iSD**: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/ · Seymour et al. 2017, PMC5648544, Table 1 and time-point response rules; Persigehl et al. 2020, PMC6942293, Responses to therapy; official iRECIST FAQ on unchanged findings versus post-iUPD response.
- **iUPD**: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/ · Seymour et al. 2017, PMC5648544, Tables 1-3, New lesions and Continued treatment after iUPD sections; official RECIST Working Group iRECIST FAQ, 4-8-week timing and clinical-stability implementation reviewed 2026-07-24.
- **iCPD**: Seymour L, Bogaerts J, Perrone A, et al.. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5648544/ · Seymour et al. 2017, PMC5648544, Table 2 and confirmation/analysis sections; official RECIST Working Group iRECIST FAQ on target, non-target, new-lesion, cross-compartment, sequential-increment and event-date rules, reviewed 2026-07-24.

## Cross-references
- _shared boundary_ → [RECIST 1.1 — Response Evaluation Criteria in Solid Tumours v1.1](https://radcommons.laudos.ai/systems/recist-1-1.md) — iRECIST starts with RECIST 1.1 measurement rules but adds separate new-lesion tracking and a longitudinal iUPD/iCPD confirmation state machine for protocol-specified immunotherapy trials. Do not export the immune confirmation states into conventional RECIST 1.1.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-10 | revised | The official RECIST Working Group iRECIST implementation page and FAQ was updated with operational clarifications; it does not create a new numbered iRECIST version or convert the framework into a treatment guideline. | confirmed |
| 2017-03-01 | published | iRECIST guideline published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/irecist · API JSON: https://radcommons.laudos.ai/api/v1/systems/irecist · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# mRECIST — Modified RECIST for hepatocellular carcinoma

> Assesses HCC treatment response using viable (enhancing) tumor.

**Status:** current · **Organ:** Oncology · **Issuing body:** Oncology imaging consensus · **Version:** 2010 · **Year:** 2010

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma (2010) — https://doi.org/10.1055/s-0030-1247132
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| CR | Complete response | Complete Response: disappearance of all arterially enhancing (viable) tumor tissue, i.e. loss of any intratumoral arterial-phase hyperenhancement across all target and non-target HCC lesions. | — | — | PMC5771991 (Voizard et al., 'Locoregional Therapies for Hepatocellular Carcinoma and the New LI-RADS Treatment Response Algorithm') Table 4 'Overview of Response Criteria and Categories', mRECIST row ('Disappearance of any intratumoral APHE in all target and non-target lesions'); cross-checked PMC4624170 'Evaluation of treatment response' ('absence of arterially enhanced areas in all target lesions') | ✓ |
| PR | Partial response | Partial Response: at least a 30% reduction in the sum of the diameters of the viable (arterially enhancing) portions of target lesions, referenced to the baseline sum. | — | — | PMC5771991 Table 4 mRECIST row ('>=30% decrease in the sum of diameters of viable target lesions'); reference is baseline per article text; cross-checked PMC4624170 'Evaluation of treatment response' ('>30% decrease' in sum of diameters of arterially enhanced areas vs baseline) | ✓ |
| SD | Stable disease | Stable Disease: viable enhancing tumor that shrinks too little to qualify as partial response and grows too little to qualify as progressive disease. | — | — | PMC5771991 Table 4 mRECIST row ('Any cases that do not qualify for either partial response or progressive disease'); cross-checked PMC4624170 'Evaluation of treatment response' ('Neither PR nor PD') | ✓ |
| PD | Progressive disease | Progressive Disease: at least a 20% increase in the sum of the diameters of viable (arterially enhancing) target lesions, or the appearance of one or more new lesions, or unequivocal progression of non-target disease. | — | — | PMC5771991 Table 4 mRECIST row ('>=20% increase in the sum of the diameters of viable target lesions or presence of one or more new lesions or unequivocal progression of existing non target lesions'); cross-checked PMC4624170 'Evaluation of treatment response' ('>20% increase' in sum of diameters of arterially enhanced areas) | ✓ |

### Per-category citations
- **CR**: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma (2010) — https://doi.org/10.1055/s-0030-1247132 · PMC5771991 (Voizard et al., 'Locoregional Therapies for Hepatocellular Carcinoma and the New LI-RADS Treatment Response Algorithm') Table 4 'Overview of Response Criteria and Categories', mRECIST row ('Disappearance of any intratumoral APHE in all target and non-target lesions'); cross-checked PMC4624170 'Evaluation of treatment response' ('absence of arterially enhanced areas in all target lesions')
- **PR**: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma (2010) — https://doi.org/10.1055/s-0030-1247132 · PMC5771991 Table 4 mRECIST row ('>=30% decrease in the sum of diameters of viable target lesions'); reference is baseline per article text; cross-checked PMC4624170 'Evaluation of treatment response' ('>30% decrease' in sum of diameters of arterially enhanced areas vs baseline)
- **SD**: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma (2010) — https://doi.org/10.1055/s-0030-1247132 · PMC5771991 Table 4 mRECIST row ('Any cases that do not qualify for either partial response or progressive disease'); cross-checked PMC4624170 'Evaluation of treatment response' ('Neither PR nor PD')
- **PD**: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma (2010) — https://doi.org/10.1055/s-0030-1247132 · PMC5771991 Table 4 mRECIST row ('>=20% increase in the sum of the diameters of viable target lesions or presence of one or more new lesions or unequivocal progression of existing non target lesions'); cross-checked PMC4624170 'Evaluation of treatment response' ('>20% increase' in sum of diameters of arterially enhanced areas)

## Cross-references
- _shared boundary_ → [RECIST 1.1 — Response Evaluation Criteria in Solid Tumours v1.1](https://radcommons.laudos.ai/systems/recist-1-1.md) — mRECIST adapts RECIST 1.1 to measure viable enhancing tumor in HCC.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mrecist · API JSON: https://radcommons.laudos.ai/api/v1/systems/mrecist · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# GI-RADS — Gynecologic Imaging Reporting and Data System

> Five-category transvaginal-ultrasound framework for one adnexal mass, combining pattern recognition, a count of defined suspicious features and estimated malignancy bands. Preserve the original GI-RADS definitions and risk ranges; do not translate a category number into O-RADS, IOTA ADNEX or a treatment order.

**Status:** current · **Organ:** Ovary/Adnexa · **Issuing body:** Amor et al. / gynecologic ultrasound literature · **Version:** 2009 proposal; 2011 multicenter validation; 2021 consensus context · **Year:** 2011

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Use the exact original category definitions and estimated risk bands. Count the five defined suspicious-feature groups explicitly; GI-RADS 5 requires at least three. Keep current O-RADS/IOTA triage and individualized management separate.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | GI-RADS 1, definitively benign | GI-RADS 1, definitively benign: a complete ultrasound examination identifies normal ovaries and no adnexal mass. Nonvisualization of an ovary, incomplete coverage or a technically limited examination must not be converted into category 1. | No mass-specific follow-up was suggested in the original framework after a complete normal examination. Symptoms or another clinical indication are managed separately; the numeral is not a general no-follow-up order. | Original estimated probability of malignancy is 0% for the defined no-mass state. This framework estimate is not proof that no pelvic malignancy exists outside the examined adnexa and is not a personal lifetime-risk estimate. | Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 1 and original management suggestions; Amor et al. 2009, PMID 19244063, five-category proposal; Timmerman et al. 2021, DOI 10.1002/uog.23635, GI-RADS risk-band summary and current diagnostic context. | ✓ |
| 2 | GI-RADS 2, very probably benign | GI-RADS 2, very probably benign: an adnexal finding with a characteristic functional origin, such as a follicle, corpus luteum or hemorrhagic cyst, on an adequately characterized ultrasound examination. | The 2011 framework suggested follow-up ultrasound for a presumed functional lesion. Contemporary interval and need for follow-up depend on lesion type, size, symptoms, menopausal status and the current institutional system; category 2 alone does not set an interval. | Original estimated probability of malignancy is less than 1%. This is a category band rather than an individualized probability, and a lesion that lacks the required classic functional pattern must not inherit the band. | Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 2 and suggested follow-up; Amor et al. 2009, DOI 10.7863/jum.2009.28.3.285, original expectant-management cohort; Timmerman et al. 2021, DOI 10.1002/uog.23635. | ✓ |
| 3 | GI-RADS 3, probably benign | GI-RADS 3, probably benign: a recognizable persistent lesion thought benign, including an endometrioma, teratoma, simple cyst, hydrosalpinx, paraovarian cyst, peritoneal pseudocyst, pedunculated myoma or pelvic-inflammatory-disease pattern, without defined suspicious features. | The multicenter GI-RADS paper suggested laparoscopic surgery for category 3 in its validation-era pathway. That is not a universal contemporary mandate: expert ultrasound, current O-RADS or IOTA guidance, symptoms, size, growth, menopausal status and patient goals determine surveillance or intervention. | Original estimated probability of malignancy is 1-4%. The band assumes that the benign pattern is confidently recognized; observed malignancy proportions from a selected validation cohort are not interchangeable with this estimate or transferable to one patient. | Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 3 and original laparoscopic-surgery suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, Statements 1-4 favoring expert assessment and validated IOTA models for current triage. | ✓ |
| 4 | GI-RADS 4, probably malignant | GI-RADS 4, probably malignant: a lesion not meeting categories 1-3 and showing exactly one or two defined suspicious findings: thick papillary projections, thick septations, solid areas, ascites, or vascularization within a solid area or papillary projection or centrally within a solid tumor. | The original clinical-practice framework suggested referral to a gynecologic oncologist. Current triage should be prompt and protocol-based, integrating expert ultrasound, clinical factors and an appropriate contemporary model; the category does not itself diagnose cancer or dictate CT, MRI, biomarkers or surgery. | Original estimated probability of malignancy is 5-20%. GI-RADS 4 and 5 are often combined as a high-risk test-positive group, but this category retains its own band and must not be translated into O-RADS 4, whose definitions and risk range differ. | Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 4, suspicious-feature footnote and referral suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, GI-RADS bands and current expert/IOTA triage statements. | ✓ |
| 5 | GI-RADS 5, very probably malignant | GI-RADS 5, very probably malignant: an adnexal mass with three or more defined suspicious findings among thick papillary projections, thick septations, solid areas, ascites, and suspicious central or solid-component/papillary vascularization. Two findings remain category 4, not 5. | The original framework suggested referral to a gynecologic oncologist. Contemporary work-up and treatment require expert characterization, clinical context and the applicable oncology pathway; GI-RADS 5 is neither pathologic confirmation nor an automatic staging, biopsy or operation order. | Original estimated probability of malignancy is greater than 20%. The lower bound is specific to GI-RADS and is not equivalent to the substantially different O-RADS 5 band; validation-cohort positive predictive values must not be used as a personal probability. | Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 5 requiring three or more suspicious findings, feature footnote and referral suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, multisociety risk-band and system-boundary context. | ✓ |

### Per-category citations
- **1**: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012 · Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 1 and original management suggestions; Amor et al. 2009, PMID 19244063, five-category proposal; Timmerman et al. 2021, DOI 10.1002/uog.23635, GI-RADS risk-band summary and current diagnostic context.
- **2**: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012 · Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 2 and suggested follow-up; Amor et al. 2009, DOI 10.7863/jum.2009.28.3.285, original expectant-management cohort; Timmerman et al. 2021, DOI 10.1002/uog.23635.
- **3**: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012 · Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 3 and original laparoscopic-surgery suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, Statements 1-4 favoring expert assessment and validated IOTA models for current triage.
- **4**: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012 · Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 4, suspicious-feature footnote and referral suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, GI-RADS bands and current expert/IOTA triage statements.
- **5**: Amor F, Alcázar JL, Vaccaro H, et al.. GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study (2011) — https://doi.org/10.1002/uog.9012 · Amor et al. 2011, DOI 10.1002/uog.9012, Table 1 category 5 requiring three or more suspicious findings, feature footnote and referral suggestion; Timmerman et al. 2021, DOI 10.1002/uog.23635, multisociety risk-band and system-boundary context.

## Cross-references
- _shared boundary_ → [O-RADS US — Ovarian-Adnexal Reporting and Data System, ultrasound](https://radcommons.laudos.ai/systems/o-rads-us-2020.md) — Both stratify adnexal findings on ultrasound, but their definitions, risk bands and management differ. Never translate GI-RADS 1-5 into O-RADS 1-5 by number.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2021-06-01 | revised | The ESGO/ISUOG/IOTA/ESGE consensus retained GI-RADS as a described risk system while preferring expert subjective assessment or validated IOTA models for contemporary preoperative discrimination; this is context, not a change to GI-RADS category thresholds. | confirmed |
| 2011-10-01 | revised | The prospective multicenter clinical-practice study validated the structured report, corrected here to DOI 10.1002/uog.9012, and stated the original management suggestions. | confirmed |
| 2009-03-01 | published | Amor and colleagues proposed the five-category transvaginal-ultrasound GI-RADS framework and evaluated it against pathology in 171 women. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/gi-rads · API JSON: https://radcommons.laudos.ai/api/v1/systems/gi-rads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# O-RADS MRI — Ovarian-Adnexal Reporting and Data System, MRI

> MRI risk stratification of adnexal lesions.

**Status:** current · **Organ:** Ovary/Adnexa · **Issuing body:** American College of Radiology · **Version:** 2021 · **Year:** 2021

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | O-RADS MRI 1 | Normal ovaries / no adnexal lesion: non-ovarian lesion, or a normal physiologic structure such as a follicle (simple cyst <=3 cm), corpus luteum, or hemorrhagic cyst. | No follow-up or additional imaging needed for the ovaries. | No assigned malignancy risk (normal ovaries). | PMC9254700, Table 1 'O-RADS MRI scoring system' (Materials and Methods): Score 1 'Normal ovaries' = 'Non-ovarian lesion. Follicle (simple cyst <= 3 cm), corpus luteum, or hemorrhagic cyst'; PPV listed as not applicable. Management per ACR O-RADS MRI committee guideline (Sadowski/Thomassin-Naggara, Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672). | ✓ |
| 2 | O-RADS MRI 2, almost certainly benign | Almost certainly benign lesion: unilocular cyst with simple or endometriotic fluid content, with a smooth enhancing wall and no enhancing solid tissue. | No further imaging generally required; managed by the gynecologist as clinically indicated. | PPV for malignancy < 0.5%. | PMC9254700, Table 1 'O-RADS MRI scoring system': Score 2 (Almost certainly benign) = 'Unilocular cyst with simple or endometrial fluid content (smooth enhancing wall and no enhancing solid tissue)', PPV < 0.5%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672). | ✓ |
| 3 | O-RADS MRI 3, low risk | Low-risk lesion: unilocular cyst with proteinaceous, hemorrhagic, or mucinous fluid content, with a smooth enhancing wall and no enhancing solid tissue. | Consider short-interval follow-up (e.g. ultrasound within ~6 months) if not excised; specialist MRI or gynecologist referral as needed for solid components. | PPV for malignancy approximately 5%. | PMC9254700, Table 1 'O-RADS MRI scoring system': Score 3 (Low risk) = 'Unilocular cyst with proteinaceous, hemorrhagic or mucinous fluid content (smooth enhancing wall and no enhancing solid tissue)', PPV ~ 5%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672). | ✓ |
| 4 | O-RADS MRI 4, intermediate risk | Intermediate-risk lesion: a lesion containing enhancing solid tissue showing an intermediate-risk (type 2) time-intensity curve on dynamic contrast-enhanced (DCE) MRI. | Gynecologic oncology consultation or referral; evaluation per a gynecologic-oncology protocol given the substantial malignancy risk. | PPV for malignancy approximately 50%. | PMC9254700, Table 1 'O-RADS MRI scoring system': Score 4 (Intermediate risk) = 'Lesion with solid tissue: intermediate-risk (type 2) time-intensity curve on DCE MRI', PPV ~ 50%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672). | ✓ |
| 5 | O-RADS MRI 5, high risk | High-risk lesion: a lesion containing enhancing solid tissue showing a high-risk time-intensity curve on dynamic contrast-enhanced (DCE) MRI (or peritoneal/serosal/mesenteric implants). | Direct gynecologic oncology referral; management per gynecologic-oncology protocol. | PPV for malignancy approximately 90%. | PMC9254700, Table 1 'O-RADS MRI scoring system': Score 5 (High risk) = 'Lesion with solid tissue: high risk time-intensity curve on DCE MRI', PPV ~ 90%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672). | ✓ |

### Per-category citations
- **1**: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/ · PMC9254700, Table 1 'O-RADS MRI scoring system' (Materials and Methods): Score 1 'Normal ovaries' = 'Non-ovarian lesion. Follicle (simple cyst <= 3 cm), corpus luteum, or hemorrhagic cyst'; PPV listed as not applicable. Management per ACR O-RADS MRI committee guideline (Sadowski/Thomassin-Naggara, Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672).
- **2**: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/ · PMC9254700, Table 1 'O-RADS MRI scoring system': Score 2 (Almost certainly benign) = 'Unilocular cyst with simple or endometrial fluid content (smooth enhancing wall and no enhancing solid tissue)', PPV < 0.5%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672).
- **3**: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/ · PMC9254700, Table 1 'O-RADS MRI scoring system': Score 3 (Low risk) = 'Unilocular cyst with proteinaceous, hemorrhagic or mucinous fluid content (smooth enhancing wall and no enhancing solid tissue)', PPV ~ 5%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672).
- **4**: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/ · PMC9254700, Table 1 'O-RADS MRI scoring system': Score 4 (Intermediate risk) = 'Lesion with solid tissue: intermediate-risk (type 2) time-intensity curve on DCE MRI', PPV ~ 50%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672).
- **5**: Thomassin-Naggara I, Belghitti M, Milon A, et al.. O-RADS MRI risk stratification system for adnexal lesions (2021) — https://pmc.ncbi.nlm.nih.gov/articles/PMC9254700/ · PMC9254700, Table 1 'O-RADS MRI scoring system': Score 5 (High risk) = 'Lesion with solid tissue: high risk time-intensity curve on DCE MRI', PPV ~ 90%. Management per ACR O-RADS MRI committee guideline (Radiology 2022, doi 10.1148/radiol.204371; PMID 35040672).

## Cross-references
- _escalates to_ → [O-RADS US — Ovarian-Adnexal Reporting and Data System, ultrasound](https://radcommons.laudos.ai/systems/o-rads-us-2020.md) — O-RADS MRI is used to further characterize indeterminate lesions seen on O-RADS US.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2021-01-01 | published | O-RADS MRI risk stratification system published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/o-rads-mri · API JSON: https://radcommons.laudos.ai/api/v1/systems/o-rads-mri · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# O-RADS US — Ovarian-Adnexal Reporting and Data System, ultrasound

> Ultrasound risk stratification and management of adnexal lesions.

**Status:** current · **Organ:** Ovary/Adnexa · **Issuing body:** American College of Radiology · **Version:** US 2019 · **Year:** 2020

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Incomplete evaluation | Incomplete evaluation: the adnexa or lesion cannot be adequately assessed on the available ultrasound study (insufficient/incomplete imaging). | A repeat (or otherwise completed) ultrasound examination is recommended to adequately characterize the adnexa. | — | Criteria: Front Pediatr 2023 (PMC10030612), O-RADS category list ('O-RADS 0: incomplete evaluation'); corroborated appliedradiology.com. Management: PMC9327748 ('O-RADS 0 ... a repeat ultrasound examination is recommended') | ✓ |
| 1 | Normal ovary, physiologic | Normal ovary / definitively benign physiologic finding (e.g., a normal premenopausal ovary, including follicles and corpus luteum); no discrete lesion meeting higher-category descriptors. | No lesion-specific imaging follow-up is necessary for a normal ovary or definitively benign physiologic finding; subsequent care follows the clinical context. | — | Criteria: Front Pediatr 2023 (PMC10030612), O-RADS category list ('O-RADS 1: definitively benign. Normal ovaries'); corroborated appliedradiology.com. Management: PMC9327748 ('O-RADS 1 ... follow-up is not necessary') | ✓ |
| 2 | Almost certainly benign | Almost certainly benign lesion: classic benign appearances such as a simple cyst, classic hemorrhagic cyst, classic dermoid (mature cystic teratoma), classic endometrioma, para-ovarian cyst, peritoneal inclusion cyst, or hydrosalpinx; also unilocular cysts up to about 10 cm with smooth inner walls and no solid component. | For lesions with classic benign ultrasound features, no further evaluation is generally required on identification; certain subtypes warrant short-interval follow-up ultrasound (e.g., larger hemorrhagic cysts and endometriomas) as described in the source. | Almost certainly benign, with less than 1% risk of malignancy. | Risk band from Front Pediatr 2023 (PMC10030612) ('O-RADS 2: almost certainly benign category (<1% risk of malignancy)') and JAMA Netw Open 2022 (PMC9185186) Discussion ('O-RADS US 2 was 0.5%, (<1%; expected)'); descriptors and management from appliedradiology.com O-RADS section and the reproduced ACR O-RADS US Risk Stratification Table (PMC9185186 Figure 1) | ✓ |
| 3 | Low risk of malignancy | Low-risk lesion: e.g., a unilocular cyst 10 cm or larger with smooth inner wall, a multilocular cyst smaller than 10 cm with smooth inner wall and color score 1-3, a unilocular cyst with an irregular inner wall (less than 3 mm), or a smooth-contoured solid lesion of any size with color score 1. | Further characterization by management with an ultrasound specialist or by MRI (the two considered equivalent for O-RADS 3) is recommended; MRI is particularly valuable in postmenopausal patients. | Low risk, 1% to less than 10% risk of malignancy (stated as 1-9% in the corroborating source). | Risk band from Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 4.5%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 (US specialist equivalent to MRI for O-RADS 3) and appliedradiology.com ('MRI may be valuable') | ✓ |
| 4 | Intermediate risk of malignancy | Intermediate-risk lesion: e.g., multilocular cyst 10 cm or larger (or any size with color score 4), multilocular cyst with irregular wall/septation, unilocular cyst with a solid component and 0-3 papillary projections (any color score), multilocular cyst with a solid component and color score 1-2, or a smooth-contoured solid lesion with color score 2-3. | Consultation with a gynecologic oncologist is recommended; further characterization by MRI (or an ultrasound specialist, considered equivalent to MRI for O-RADS 3-4) may be used. | Intermediate risk, 10% to less than 50% risk of malignancy. | Risk band: Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 11.6%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 ('O-RADS 4 ... consultation with gynecologic oncologist'; US specialist equivalent to MRI for 3-4) | ✓ |
| 5 | High risk of malignancy | High-risk lesion: e.g., unilocular cyst with 4 or more papillary projections (any color score), multilocular cyst with a solid component and color score 3-4, smooth-contoured solid lesion with color score 4, any solid lesion with irregular outer contour (any color score), or any O-RADS 3-5 lesion accompanied by ascites and/or peritoneal nodules. | Direct referral to a gynecologic oncologist is recommended. | High risk, 50% or greater risk of malignancy. | Risk band: Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 65.6%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 ('O-RADS 5 ... direct referral to a gynecologic oncologist is recommended') | ✓ |

### Per-category citations
- **0**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Criteria: Front Pediatr 2023 (PMC10030612), O-RADS category list ('O-RADS 0: incomplete evaluation'); corroborated appliedradiology.com. Management: PMC9327748 ('O-RADS 0 ... a repeat ultrasound examination is recommended')
- **1**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Criteria: Front Pediatr 2023 (PMC10030612), O-RADS category list ('O-RADS 1: definitively benign. Normal ovaries'); corroborated appliedradiology.com. Management: PMC9327748 ('O-RADS 1 ... follow-up is not necessary')
- **2**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Risk band from Front Pediatr 2023 (PMC10030612) ('O-RADS 2: almost certainly benign category (<1% risk of malignancy)') and JAMA Netw Open 2022 (PMC9185186) Discussion ('O-RADS US 2 was 0.5%, (<1%; expected)'); descriptors and management from appliedradiology.com O-RADS section and the reproduced ACR O-RADS US Risk Stratification Table (PMC9185186 Figure 1)
- **3**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Risk band from Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 4.5%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 (US specialist equivalent to MRI for O-RADS 3) and appliedradiology.com ('MRI may be valuable')
- **4**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Risk band: Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 11.6%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 ('O-RADS 4 ... consultation with gynecologic oncologist'; US specialist equivalent to MRI for 3-4)
- **5**: Andreotti RF, Timmerman D, Strachowski LM, et al.. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee (2020) — https://doi.org/10.1148/radiol.2019191150 · Risk band: Front Pediatr 2023 (PMC10030612) and JAMA Netw Open 2022 (PMC9185186, observed 65.6%); descriptors from reproduced ACR Risk Stratification Table (PMC9185186 Fig 1) and JAMA Table 2. Management: PMC9327748 ('O-RADS 5 ... direct referral to a gynecologic oncologist is recommended')

## Cross-references
- _escalates to_ → [O-RADS MRI — Ovarian-Adnexal Reporting and Data System, MRI](https://radcommons.laudos.ai/systems/o-rads-mri.md) — Indeterminate adnexal lesions on ultrasound are escalated to O-RADS MRI.
- _shared boundary_ → [BI-RADS — Breast Imaging Reporting and Data System, 5th edition](https://radcommons.laudos.ai/systems/bi-rads-2013.md) — Shares the ACR Reporting and Data System framework that BI-RADS established.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-23 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-21 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-20 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-19 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-18 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-17 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-16 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-15 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2020-01-01 | published | O-RADS US consensus guideline published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/o-rads-us-2020 · API JSON: https://radcommons.laudos.ai/api/v1/systems/o-rads-us-2020 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# AAST Pancreas — AAST Pancreas Organ Injury Scale

> Current grade I-V anatomic pancreatic-trauma scale replacing the 1990 location-heavy map. Grade I is edema or contusion without laceration; II has intact duct or a shallow uninvestigated laceration/hematoma; III and IV stratify injuries at the 50% depth and portal-vein/SMV boundaries with N/A/B duct subgrades; V is destructive nonviable head injury with A-D pancreatobiliary subgrades. CT appearance alone may not establish main-duct integrity, and grade does not autonomously prescribe treatment or prognosis.

**Status:** current · **Organ:** Pancreas · **Issuing body:** American Association for the Surgery of Trauma · **Version:** 2024 revision (published 2025); imaging context reviewed through 2026 · **Year:** 2025

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI/MRCP, ERCP, Surgery, Pathology
- Primary source: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Use the 2024 revision with a main grade and subgrade, preserve the 50-percent and PV/SMV boundaries, and never infer duct integrity or treatment from CT grade alone.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I, edema or contusion without laceration | Pancreatic edema or contusion without laceration or hematoma. Subgrade I-A denotes traumatic edema and I-B denotes contusion without hematoma or laceration; head location no longer elevates an intact low-grade injury. | A hemodynamically stable patient without another laparotomy indication is generally considered for observation and nonoperative management, with reassessment when symptoms, enzymes or secondary imaging signs remain concerning. The current grade does not replace associated-injury evaluation. | Grade I is the least anatomic injury tier but does not guarantee absence of delayed pancreatic findings or complications. No portable patient-level fistula, pseudocyst or mortality percentage is encoded. | Notrica et al. 2025, DOI 10.1097/TA.0000000000004522, revised Table 1 grade I and I-A/I-B; Lanier and Mellnick 2026 for early-imaging limitations; WSES-AAST 2019 for stable-patient care context. | ✓ |
| II | Grade II, intact duct or shallow uninvestigated laceration/hematoma | Main pancreatic duct confirmed intact, or parenchymal laceration or hematoma less than 50% depth without definitive duct evaluation, or a lesion at least 50% deep with a definitively intact duct. Subgrade II-A is neck/body/tail and II-B is head/uncinate. | Stable grade II injury is often managed nonoperatively when no other operation is required, but a shallow uninvestigated lesion does not prove duct integrity. Escalate duct assessment when mechanism, depth, evolution or clinical findings could change care; laceration of the head with an intact duct is II-B rather than legacy grade IV. | Grade II contains both confirmed-intact-duct injuries and shallow lesions without definitive duct interrogation, so it is not one homogeneous risk group. Diagnostic delay and missed duct injury materially affect complications. | Notrica et al. 2025 revised Table 1, grade II and II-A/II-B; current imaging review for CT-versus-duct-evaluation limits; WSES-AAST 2019 management context, explicitly predating the new subgrades. | ✓ |
| III | Grade III, deep or ductal neck/body/tail injury | Main pancreatic duct injury or laceration or hematoma at least 50% deep in the neck, body or tail, defined as overlying or left of the portal vein or superior mesenteric vein. III-N lacks definitive duct evaluation, III-A has confirmed injury with maintained duct alignment, and III-B has complete transection or distracted ends. | Obtain early multidisciplinary trauma, hepatopancreatobiliary, interventional-endoscopy and radiology assessment. Resection, drainage, reconstruction, endoscopic therapy or selected nonoperative care depends on N/A/B duct status, exact location, physiology, age, associated injury, time from trauma and institutional expertise; grade III is not an automatic distal-pancreatectomy order. | Deep or confirmed ductal injury increases cohort complication burden, but III-N, III-A and III-B are clinically different and the revision is not a calibrated individual-risk model. Preserve duct uncertainty and associated injuries. | Notrica et al. 2025, revised Table 1 grade III, N/A/B subgrades and PV/SMV footnotes; Lanier and Mellnick 2026 for definitive duct-imaging emphasis; WSES-AAST 2019 for contextual management options. | ✓ |
| IV | Grade IV, deep or ductal head/uncinate injury | Main pancreatic duct injury or laceration or hematoma at least 50% deep in the head or uncinate, with any portion right of or posterior to the superior mesenteric vein. IV-N lacks definitive duct evaluation, IV-A has confirmed injury with alignment, and IV-B has complete transection or distraction. | Use urgent specialist and multidisciplinary planning, integrating duct subgrade, tissue viability, duodenal and biliary injury, hemorrhage, physiology and timing. Drainage, reconstruction, endoscopic therapy, resection or selected nonoperative strategies are context-dependent; current grade IV does not automatically require pancreaticoduodenectomy. | Grade IV identifies deep or ductal head/uncinate injury rather than a fixed prognosis. Outcome varies with partial versus complete duct injury, associated pancreatobiliary or vascular trauma, delay and center capability; no universal fistula or mortality percentage applies. | Notrica et al. 2025, revised Table 1 grade IV, IV-N/IV-A/IV-B and location footnotes; 2026 imaging review; WSES-AAST 2019 severe-injury management context, recognized as pre-revision guidance. | ✓ |
| V | Grade V, destructive nonviable pancreatic-head injury | Destructive blast or crush injury with nonviable pancreatic head. Use V-N when definitive pancreatobiliary duct assessment is unavailable; V-A for an intact main duct in the head, V-B for main pancreatic duct injury, V-C for intrapancreatic common bile duct injury, and V-D for ductal avulsion from the duodenum or sphincter disruption. | Trigger urgent damage-control and hepatopancreatobiliary planning while separately treating hemorrhage, contamination and associated duodenal, biliary and vascular injuries. The exact operation and timing depend on physiology, viability and reconstructive options; grade V alone does not mandate a Whipple procedure or establish futility. | Grade V is the highest destructive anatomic tier, but V-A through V-D represent distinct pancreatobiliary injuries and do not provide an individual survival or functional-outcome probability. Physiology and associated trauma remain decisive. | Notrica et al. 2025, revised Table 1 grade V and A-D duct subgrades with N uncertainty convention; current imaging review; WSES-AAST 2019 destructive-head management context interpreted cautiously because it predates the revision. | ✓ |

### Per-category citations
- **I**: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/ · Notrica et al. 2025, DOI 10.1097/TA.0000000000004522, revised Table 1 grade I and I-A/I-B; Lanier and Mellnick 2026 for early-imaging limitations; WSES-AAST 2019 for stable-patient care context.
- **II**: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/ · Notrica et al. 2025 revised Table 1, grade II and II-A/II-B; current imaging review for CT-versus-duct-evaluation limits; WSES-AAST 2019 management context, explicitly predating the new subgrades.
- **III**: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/ · Notrica et al. 2025, revised Table 1 grade III, N/A/B subgrades and PV/SMV footnotes; Lanier and Mellnick 2026 for definitive duct-imaging emphasis; WSES-AAST 2019 for contextual management options.
- **IV**: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/ · Notrica et al. 2025, revised Table 1 grade IV, IV-N/IV-A/IV-B and location footnotes; 2026 imaging review; WSES-AAST 2019 severe-injury management context, recognized as pre-revision guidance.
- **V**: Notrica DM, Tominaga GT, Gross JA, et al.. American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 revision (2025) — https://pubmed.ncbi.nlm.nih.gov/39898876/ · Notrica et al. 2025, revised Table 1 grade V and A-D duct subgrades with N uncertainty convention; current imaging review; WSES-AAST 2019 destructive-head management context interpreted cautiously because it predates the revision.

## Cross-references
- _shared boundary_ → [AAST Spleen — AAST splenic injury scale](https://radcommons.laudos.ai/systems/aast-spleen.md) — Companion AAST organ injury scales for abdominal trauma.
- _shared boundary_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — AAST Pancreas 2024 grades traumatic anatomy and duct integrity. Revised Atlanta classifies acute-pancreatitis morphology, collections and clinical organ-failure severity; no grade or severity crosswalk is valid.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-01-01 | revised | The current imaging review clarified CT limitations and the increased role of definitive duct evaluation under the 2024 revision; it did not alter the grade table. | confirmed |
| 2025-02-03 | revised | AAST published the 2024 pancreas OIS revision, moving intact-duct head injuries to grade II and adding explicit depth, PV/SMV location and pancreatobiliary duct subgrades. | confirmed |
| 1990-11-01 | published | AAST published the original location-heavy pancreas OIS; it is retained as historical lineage and is no longer the current definition set. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aast-pancreas · API JSON: https://radcommons.laudos.ai/api/v1/systems/aast-pancreas · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# ACR Incidental Pancreatic Cyst — ACR incidental pancreatic cyst management

> Management pathway for incidentally detected pancreatic cysts based on size and worrisome features.

**Status:** current · **Organ:** Pancreas · **Issuing body:** American College of Radiology · **Version:** 2017 · **Year:** 2017

## Provenance and currency
- Family: incidental finding
- Logic type: flat
- Modality: CT, MRI
- Primary source: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return one primary size branch plus any applicable duct or worrisome-feature flags. Preserve age, growth, MPD communication and surgical candidacy; do not turn this consensus flowchart into an automatic procedure order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| small-cyst | Small cyst | Incidental pancreatic cyst <1.5 cm in an asymptomatic adult. Chart 1 separates age <65 from age 65-79; a T2-hyperintense 'white dot' <5 mm is a special subgroup. Worrisome features, high-risk stigmata or related symptoms supersede routine size surveillance. | For age <65, reimage yearly five times, then every 2 years twice if stable, stopping after at least 9 stable years. For age 65-79, reimage every 2 years five times and stop after 10 stable years. After significant growth while still <1.5 cm, reimage yearly or consider EUS/FNA; if size reaches >=1.5 cm, move to Chart 2 or EUS/FNA. For a <5 mm white-dot lesion, one CT or MRI at 2 years is enough to stop if stable. Surveillance generally ends at age 80. | Most small presumed mucinous cysts are expected to be indolent, but the paper states that accurate malignant-transformation rates for small incidental cysts are unknown. Size alone is not a calibrated individual risk estimate. | Megibow et al., JACR 2017, Fig. 1/Chart 1 and legend; pp.6-9 length of follow-up, reporting, applicability and Chart 1 explanation. | ✓ |
| intermediate-cyst | Intermediate size cyst | Incidental pancreatic cyst 1.5-2.5 cm in an asymptomatic adult. Chart 2A applies when cyst-main-pancreatic-duct communication is established; Chart 2B applies when communication is absent or cannot be determined. Worrisome features or high-risk stigmata trigger the escalation pathway regardless of the routine schedule. | With MPD communication, a 1.5-1.9 cm cyst is reimaged yearly for 5 years then every 2 years twice; a 2.0-2.5 cm cyst is reimaged every 6 months four times, yearly twice, then every 2 years three times. EUS/FNA at detection is an alternative. Without or with unknown MPD communication, either use EUS/FNA or reimage every 6 months four times, yearly twice, then every 2 years three times. Growth to >2.5 cm prompts EUS/FNA; result-dependent paths distinguish SCA/cPNET/pseudocyst from mucinous or indeterminate aspiration. | The 1.5-2.5 cm band has no single malignancy percentage. Risk assessment depends on duct communication, growth, mural or wall findings, duct caliber, symptoms and sampling rather than size alone. | Megibow et al., JACR 2017, Fig. 2/Charts 2A-2B and legends; pp.9-10 Chart 2 explanation and follow-up horizon. | ✓ |
| large-cyst | Large cyst | Incidental pancreatic cyst >2.5 cm. Chart 3 separates a diagnosed serous cystadenoma, low-risk imaging, high-risk imaging and direct EUS/FNA. Low-risk imaging means no mural nodule, no wall thickening, normal-caliber MPD and no peripheral calcification; high-risk imaging includes the converse features, with the standardized worrisome/high-risk definitions assessed separately. | For low-risk imaging, reimage every 6 months four times, then yearly twice and every 2 years three times, stopping after 10 stable years. High-risk imaging prompts EUS/FNA plus surgical consultation. A symptomatic SCA or SCA >4 cm merits surgical consultation; any cyst should undergo EUS/FNA before contemplated resection. For a patient >=80 at presentation, use the separate 2.5 cm Chart 4, generally reimaging a low-risk lesion every 2 years twice and pursuing EUS/FNA only when health, preferences and surgical candidacy support it. | A >2.5 cm cyst receives closer evaluation, but this size branch is not a numeric malignancy probability. High-grade dysplasia or malignancy can occur below 3 cm, which is why the ACR chose 2.5 cm for this management chart. | Megibow et al., JACR 2017, Fig. 3/Chart 3 and Fig. 4/Chart 4 with legends; pp.9-10 Chart 3-4 explanations. | ✓ |
| worrisome-features | Worrisome features present | ACR 2017 worrisome features are cyst >=3 cm, thickened or enhancing cyst wall, nonenhancing mural nodule, or MPD caliber >=7 mm. High-risk stigmata are obstructive jaundice with a pancreatic-head cyst, an enhancing solid component or enhancing mural nodule, or MPD >=10 mm without obstruction. | A worrisome feature or high-risk stigma prompts EUS with FNA and surgical consultation. The stated exception is size >=3 cm as the only worrisome feature: if no other worrisome feature or high-risk stigma is present, imaging follow-up is an alternative. New symptoms terminate the incidental-cyst algorithm and require clinical evaluation. | These are qualitative escalation features rather than calibrated malignancy probabilities. An enhancing component, obstructive jaundice or MPD >=10 mm carries the stronger high-risk-stigma label; cyst size >=3 cm alone has an explicit surveillance alternative. | Megibow et al., JACR 2017, Table 1; pp.7-9 reporting consideration 4, applicability and common principle 4; Charts 1-4 escalation footnotes. | ✓ |
| main-duct-involvement | Main pancreatic duct involvement | Cyst-MPD communication and/or main pancreatic duct dilation. Communication establishes a branch-duct or combined IPMN pattern; record the widest MPD diameter even away from the cyst. MPD >=7 mm is a worrisome feature and MPD >=10 mm without obstruction is a high-risk stigma. | Use CT with 3D reconstructions or MRI/MRCP to assess communication. In a 1.5-2.5 cm cyst, confirmed communication selects Chart 2A; absent or indeterminate communication selects Chart 2B. Dilated MPD prompts EUS/FNA and surgical evaluation according to the 7 mm and 10 mm escalation thresholds rather than routine surveillance alone. | The paper cites disease-level malignancy rates of 38%-65% for combined-form and 38%-68% for main-duct IPMN, but those cohort ranges are not an individual risk estimate for every cyst with duct communication or dilation. | Megibow et al., JACR 2017, pp.4-5 clinical-importance histology context; pp.7-8 reporting consideration 3 and Table 1; Fig. 2/Charts 2A-2B. | ✓ |

### Per-category citations
- **small-cyst**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, Fig. 1/Chart 1 and legend; pp.6-9 length of follow-up, reporting, applicability and Chart 1 explanation.
- **intermediate-cyst**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, Fig. 2/Charts 2A-2B and legends; pp.9-10 Chart 2 explanation and follow-up horizon.
- **large-cyst**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, Fig. 3/Chart 3 and Fig. 4/Chart 4 with legends; pp.9-10 Chart 3-4 explanations.
- **worrisome-features**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, Table 1; pp.7-9 reporting consideration 4, applicability and common principle 4; Charts 1-4 escalation footnotes.
- **main-duct-involvement**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, pp.4-5 clinical-importance histology context; pp.7-8 reporting consideration 3 and Table 1; Fig. 2/Charts 2A-2B.

## Cross-references
- _shared boundary_ → [ACR Incidental Adrenal — ACR incidental adrenal mass management](https://radcommons.laudos.ai/systems/acr-incidental-adrenal-2017.md) — Both are ACR Incidental Findings Committee white papers in the same series.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2017-07-01 | published | ACR Incidental Findings Committee pancreatic cyst white paper published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/acr-incidental-panc-cyst-2017 · API JSON: https://radcommons.laudos.ai/api/v1/systems/acr-incidental-panc-cyst-2017 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Balthazar CTSI — Balthazar grade and original CT Severity Index for acute pancreatitis

> Combines Balthazar morphologic grade A-E (0-4 points) with the extent of nonenhancing pancreatic necrosis on contrast-enhanced CT (0, 2, 4 or 6 points) into an original CTSI total of 0-10.

**Status:** current · **Organ:** Pancreas · **Issuing body:** Balthazar et al. / Radiology · **Version:** 1990 · **Year:** 1990

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT
- Primary source: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Calculate the original 1990 CTSI only: preserve both components, their points and the exact 0-10 total. Keep modified CTSI and Revised Atlanta severity explicitly separate.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Balthazar grade A, 0 morphologic points | Balthazar morphologic grade A: normal pancreas and no peripancreatic inflammatory abnormality on CT; contributes 0 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 0 points with the necrosis component, report the exact CTSI total, and use the result as one prognostic imaging input alongside the patient's clinical status. | Grade A contributes the minimum morphologic burden, but grade A alone is not a mortality or complication estimate because the total CTSI also depends on pancreatic necrosis. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: normal pancreas=0 points; PMID 2296641. | ✓ |
| B | Balthazar grade B, 1 morphologic point | Balthazar morphologic grade B: focal or diffuse enlargement of the pancreas, contributing 1 morphologic point to the original CTSI. | This component does not prescribe treatment. Combine its 1 point with the necrosis component, report the exact CTSI total, and use the result as one prognostic imaging input alongside the patient's clinical status. | Grade B contributes 1 point to CT severity, but it is not a standalone outcome-risk estimate; overall risk depends on the complete CTSI and clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: focal or diffuse enlargement=1 point; PMID 2296641. | ✓ |
| C | Balthazar grade C, 2 morphologic points | Balthazar morphologic grade C: intrinsic pancreatic abnormality with inflammatory change in the peripancreatic fat, contributing 2 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 2 points with the necrosis component, report the exact CTSI total, and separately describe the current morphology and clinical severity. | Grade C contributes 2 points to CT severity, but it is not a standalone outcome-risk estimate; overall risk depends on the complete CTSI and clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: pancreatic abnormality plus peripancreatic inflammation=2 points; PMID 2296641. | ✓ |
| D | Balthazar grade D, 3 morphologic points | Balthazar morphologic grade D: one ill-defined peripancreatic fluid collection or phlegmon in the original terminology, contributing 3 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 3 points with the necrosis component and describe the collection using current acute-pancreatitis morphology and timing rather than relying on the historical term alone. | Grade D contributes 3 points to CT severity, but it is not a standalone outcome-risk estimate; the complete CTSI and clinical course determine prognostic context. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: single ill-defined collection or phlegmon=3 points; Revised Atlanta consensus, Gut 2013, section on pancreatic/peripancreatic collections, for current terminology. | ✓ |
| E | Balthazar grade E, 4 morphologic points | Balthazar morphologic grade E: two or more poorly defined peripancreatic fluid collections, or gas in or adjacent to the pancreas, contributing 4 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 4 points with the necrosis component; explicitly describe collections, necrotic content and gas because those findings require clinical interpretation beyond the historical grade. | Grade E contributes the maximum 4 morphologic points, but it is not a standalone outcome-risk estimate; the complete CTSI and clinical course determine prognostic context. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: multiple collections or gas=4 points; Revised Atlanta consensus, Gut 2013, infected-necrosis and collection definitions. | ✓ |
| N0 | No pancreatic necrosis, 0 necrosis points | No pancreatic parenchymal necrosis on an adequately enhanced contrast CT; the pancreatic gland enhances and the necrosis component contributes 0 points. | Add 0 necrosis points to the morphologic points. Absence of visible necrosis does not itself determine disposition or treatment, particularly when examination timing or contrast enhancement is suboptimal. | In the original cohort, patients without necrosis had markedly lower morbidity and no deaths, but this historical cohort result is not an individual prediction. | Balthazar et al. 1990, PMID 2296641 abstract: necrosis was defined by lack of gland enhancement; patients without necrosis had 6% morbidity and 0% mortality. Original CTSI table assigns 0 points for no necrosis. | ✓ |
| N<30 | Pancreatic necrosis below 30%, 2 necrosis points | More than 0% but less than 30% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes 2 necrosis points to the original CTSI. | Add 2 necrosis points to the morphologic points and report the estimated percentage category. The component quantifies prognostic imaging burden and does not by itself mandate an intervention. | Any pancreatic necrosis increases concern compared with no necrosis, but this component must be interpreted through the total CTSI and the patient's evolving clinical status. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: below 30%=2 points; PMID 2296641 abstract defines necrosis by lack of enhancement and evaluates extent. | ✓ |
| N30-50 | Pancreatic necrosis 30-50%, 4 necrosis points | From 30% through 50% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes 4 necrosis points to the original CTSI. | Add 4 necrosis points to the morphologic points and report the estimated percentage category. The component quantifies prognostic imaging burden and does not by itself mandate an intervention. | The original study associated more than 30% necrosis with serious complications, but the percentage remains one component of a broader clinical assessment. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: 30-50%=4 points; PMID 2296641 abstract states serious complications occurred when more than 30% necrosis was present or developed. | ✓ |
| N>50 | Pancreatic necrosis above 50%, 6 necrosis points | More than 50% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes the maximum 6 necrosis points to the original CTSI. | Add 6 necrosis points to the morphologic points and report the estimated percentage category. The component indicates substantial imaging severity but does not itself specify treatment. | This is the highest necrosis-point category and contributes strongly to a high CTSI; individual prognosis still depends on organ failure, infection and the clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: greater than 50%=6 points; PMID 2296641 abstract describes the prognostic impact of pancreatic necrosis. | ✓ |
| CTSI-0-3 | Original CTSI total 0-3, lower CT severity band | Original CTSI total from 0 through 3 after adding Balthazar morphologic points and pancreatic-necrosis points; lower CT severity band. | Use the exact total as a prognostic imaging input, not as a treatment algorithm. A lower CTSI does not override organ failure, infection, worsening symptoms or other clinical indicators. | The original study's low-index group had 2% morbidity and no deaths; these cohort figures provide historical context and are not calibrated patient-specific probabilities. | Balthazar et al. 1990, PMID 2296641 abstract: low CT severity index group had 2% morbidity and no mortality; original CTSI total combines morphologic and necrosis points. | ✓ |
| CTSI-4-6 | Original CTSI total 4-6, intermediate CT severity band | Original CTSI total from 4 through 6 after adding Balthazar morphologic points and pancreatic-necrosis points; intermediate CT severity band. | Use the exact total as a prognostic imaging input, not as a treatment algorithm. Clinical severity and management require assessment of organ failure, complications, infection and trajectory. | This intermediate band lies between the low and high CT-burden groups; the original abstract does not provide a separate patient-level probability for every score in this range. | Balthazar et al. 1990, Radiology 174:331-336, original 0-10 CTSI construction and prognostic stratification; PMID 2296641. | ✓ |
| CTSI-7-10 | Original CTSI total 7-10, high CT severity band | Original CTSI total from 7 through 10 after adding Balthazar morphologic points and pancreatic-necrosis points; high CT severity band. | Use the exact total as a high-burden prognostic imaging input, not as a treatment algorithm. Escalation decisions require the patient's organ failure, infection, complications and overall clinical course. | The original study's high-index group had 92% morbidity and 17% mortality; these historical cohort figures are context rather than individualized probabilities. | Balthazar et al. 1990, PMID 2296641 abstract: high CT severity index group had 92% morbidity and 17% mortality; original CTSI total combines morphologic and necrosis points. | ✓ |

### Per-category citations
- **A**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: normal pancreas=0 points; PMID 2296641.
- **B**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: focal or diffuse enlargement=1 point; PMID 2296641.
- **C**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: pancreatic abnormality plus peripancreatic inflammation=2 points; PMID 2296641.
- **D**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: single ill-defined collection or phlegmon=3 points; Revised Atlanta consensus, Gut 2013, section on pancreatic/peripancreatic collections, for current terminology.
- **E**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: multiple collections or gas=4 points; Revised Atlanta consensus, Gut 2013, infected-necrosis and collection definitions.
- **N0**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: necrosis was defined by lack of gland enhancement; patients without necrosis had 6% morbidity and 0% mortality. Original CTSI table assigns 0 points for no necrosis.
- **N<30**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: below 30%=2 points; PMID 2296641 abstract defines necrosis by lack of enhancement and evaluates extent.
- **N30-50**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: 30-50%=4 points; PMID 2296641 abstract states serious complications occurred when more than 30% necrosis was present or developed.
- **N>50**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: greater than 50%=6 points; PMID 2296641 abstract describes the prognostic impact of pancreatic necrosis.
- **CTSI-0-3**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: low CT severity index group had 2% morbidity and no mortality; original CTSI total combines morphologic and necrosis points.
- **CTSI-4-6**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original 0-10 CTSI construction and prognostic stratification; PMID 2296641.
- **CTSI-7-10**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: high CT severity index group had 92% morbidity and 17% mortality; original CTSI total combines morphologic and necrosis points.

## Cross-references
- _shared boundary_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — Balthazar CTSI is a 0-10 imaging prognostic index. Revised Atlanta uses organ failure and local/systemic complications for current clinical severity; identical words such as mild or severe do not make the systems interchangeable.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2002-06-01 | revised | CT Severity Index for acute pancreatitis described. | confirmed |
| 1990-02-01 | published | Original CT Severity Index for acute pancreatitis published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/balthazar-ctsi · API JSON: https://radcommons.laudos.ai/api/v1/systems/balthazar-ctsi · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Cambridge — Cambridge classification of chronic pancreatitis morphology

> Grades chronic-pancreatitis morphology from normal through marked using a ductal ERCP/MRCP branch and an APA CT/MRI/US adaptation; modality must be retained because cross-sectional imaging alone cannot reliably separate every intermediate grade.

**Status:** current · **Organ:** Pancreas · **Issuing body:** Cambridge consensus / American Pancreatic Association · **Version:** 1984; APA multimodality adaptation 2014 · **Year:** 1984

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: ERCP, MRCP, MRI, CT, US
- Primary source: Sarner M, Cotton PB. Classification of pancreatitis (1984) — https://pmc.ncbi.nlm.nih.gov/articles/PMC1432589/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Always retain modality. Use the ductal branch when side branches and main duct are adequately shown; on CT, MRI or ultrasound alone preserve the APA II-versus-III limitation instead of inventing precision.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| normal | Grade 0, normal | Cambridge 0, normal: no abnormal signs on an adequately visualized ERCP/MRCP ductal examination and no chronic-pancreatitis morphology features on the applicable CT, MRI or ultrasound branch. | Report a normal morphology grade only with modality and technical adequacy. Normal morphology does not exclude early chronic pancreatitis; if clinical suspicion remains high, the APA recommends a stepwise clinical, cross-sectional, specialist endoscopic and functional evaluation rather than treatment based on Grade 0. | Grade 0 supplies no estimate of future pancreatitis, pain, exocrine or endocrine insufficiency, cancer or intervention. Early chronic pancreatitis can have normal ductal and cross-sectional morphology. | Conwell et al. 2014 APA guideline, Tables 5-6: normal morphology and insufficient-evidence framework; Evidence-Based Report and STEP-wise algorithm. Tirkes et al. 2018, Table 3 Grade 0 and imaging-limitations discussion. | ✓ |
| equivocal | Grade I, equivocal | Cambridge I, equivocal: one or two abnormal side branches on adequately visualized ERCP/MRCP, or exactly one APA cross-sectional base feature such as a 2-4 mm main duct, slight enlargement, heterogeneous parenchyma, a cavity under 10 mm, irregular ducts, focal pancreatitis, echogenic duct wall or irregular contour. | Equivocal morphology alone is insufficient evidence for a chronic-pancreatitis diagnosis in the APA framework. Preserve the exact feature and pursue a higher-specificity stepwise evaluation only when the history and clinical suspicion justify it; do not label or treat irreversible disease from Grade I alone. | Grade I is diagnostic uncertainty, not a low numeric risk tier. It does not quantify progression, pain, pancreatic insufficiency, malignancy or treatment need, and the isolated feature may have another cause. | Conwell et al. 2014 APA guideline, Table 5 insufficient evidence and Table 6 Grade I: fewer than three abnormal side branches or one CT/MRI/US feature; diagnostic algorithm text. Tirkes et al. 2018, Table 3 Grade I. | ✓ |
| mild | Grade II, mild | Cambridge II, mild on the ductal branch: three or more abnormal side branches without the full Grade III pattern of more than three abnormal branches plus an abnormal main pancreatic duct, and without a Grade IV marked feature. On CT/MRI/US alone, use the operational II-versus-III state when the intermediate grade cannot be separated. | In the APA evidence framework, mild morphology contributes to probable chronic pancreatitis when paired with a suggestive history or abnormal imaging context and abnormal pancreatic physiology. It is not a treatment category; characterize etiology and exocrine/endocrine function separately. | Grade II denotes mild morphologic burden but provides no per-grade probability of pain, functional failure, cancer, hospitalization or intervention. Symptoms and physiology may be discordant with morphology. | Conwell et al. 2014 APA guideline, Tables 5-6: mild imaging morphology, three or more abnormal side branches, probable-evidence requirements and CT/MRI intermediate-grade limitation. Tirkes et al. 2018, Table 3 Grade II. | ✓ |
| moderate | Grade III, moderate | Cambridge III, moderate on the ductal branch: more than three abnormal side branches together with an abnormal main pancreatic duct, without a Grade IV marked feature. The APA table states that CT/MRI morphology cannot reliably distinguish this grade from mild morphology by the base feature set alone. | Moderate ductal and parenchymal morphology is listed as definitive imaging evidence in the APA framework, but the report must still exclude a credible mimicker and describe physiology, etiology and complications. Grade III alone does not prescribe endoscopic, surgical or medical treatment. | Grade III indicates more advanced morphology than Grade II but is not a validated complication or cancer-risk percentage. Prognosis and care depend on function, pain, obstruction, stones, collections, nutrition, etiology and patient context. | Conwell et al. 2014 APA guideline, Table 5 definitive moderate/marked imaging evidence and Table 6 Grade III: abnormal main duct with more than three abnormal side branches; CT/MRI cannot distinguish from mild. Tirkes et al. 2018, Table 3 Grade III. | ✓ |
| marked | Grade IV, marked (severe) | Cambridge IV, marked or severe: the preceding moderate morphology plus at least one advanced feature, including a cavity over 10 mm, intraductal filling defect or calculus, duct obstruction or stricture, severe or gross duct irregularity/dilatation, or substantial gland enlargement in the cross-sectional adaptation. | Marked morphology is definitive imaging evidence in the APA framework and should trigger complete reporting of obstruction, stones, collections, vascular or biliary complications and cancer concern. It still does not dictate a procedure; management depends on symptoms, function, complications, anatomy and multidisciplinary assessment. | Grade IV is the greatest morphologic burden in this framework, but it supplies no individual probability of pain, insufficiency, malignancy, hospitalization or intervention. Advanced chronic change also does not exclude a superimposed pancreatic neoplasm. | Conwell et al. 2014 APA guideline, Tables 5-6 Grade IV: moderate changes plus large cavity, filling defect/calculus, obstruction, stricture, gross irregularity or enlargement; definitive-evidence context. Tirkes et al. 2018, Table 3 Grade IV and complications discussion. | ✓ |
| mild-or-moderate | Operational state: Grade II versus III unresolved on CT/MRI/US alone | Operational uncertainty state, not an additional official grade: CT, conventional MRI or ultrasound demonstrates at least two APA base morphology features without a marked feature, but no adequate ductal side-branch and main-duct assessment is available to distinguish Cambridge II from III. | Return the demonstrated feature list and the II-versus-III limitation. If the distinction would change diagnostic certainty or care, integrate history and physiology and consider specialist MRCP, secretin-enhanced MRCP or EUS as appropriate; never convert the ambiguity into a false Grade II or III. | Because the official intermediate grade is unresolved, no grade-specific risk inference is valid. Even after resolution, Cambridge morphology does not provide calibrated probabilities for symptoms, pancreatic failure, cancer or intervention. | Conwell et al. 2014 APA guideline, Table 6: CT/MRI Grade II uses at least two base features and the Grade III cell states that moderate cannot be distinguished from mild; Tables 5 and 8 show why morphology grade affects evidence nomenclature. Tirkes et al. 2018, Table 3 parallel modality branches. | ✓ |

### Per-category citations
- **normal**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6: normal morphology and insufficient-evidence framework; Evidence-Based Report and STEP-wise algorithm. Tirkes et al. 2018, Table 3 Grade 0 and imaging-limitations discussion.
- **equivocal**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 5 insufficient evidence and Table 6 Grade I: fewer than three abnormal side branches or one CT/MRI/US feature; diagnostic algorithm text. Tirkes et al. 2018, Table 3 Grade I.
- **mild**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6: mild imaging morphology, three or more abnormal side branches, probable-evidence requirements and CT/MRI intermediate-grade limitation. Tirkes et al. 2018, Table 3 Grade II.
- **moderate**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 5 definitive moderate/marked imaging evidence and Table 6 Grade III: abnormal main duct with more than three abnormal side branches; CT/MRI cannot distinguish from mild. Tirkes et al. 2018, Table 3 Grade III.
- **marked**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6 Grade IV: moderate changes plus large cavity, filling defect/calculus, obstruction, stricture, gross irregularity or enlargement; definitive-evidence context. Tirkes et al. 2018, Table 3 Grade IV and complications discussion.
- **mild-or-moderate**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 6: CT/MRI Grade II uses at least two base features and the Grade III cell states that moderate cannot be distinguished from mild; Tables 5 and 8 show why morphology grade affects evidence nomenclature. Tirkes et al. 2018, Table 3 parallel modality branches.

## Cross-references
- _shared boundary_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — Cambridge grades chronic pancreatitis ductal severity; the revised Atlanta classification grades acute pancreatitis.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2014-11-01 | revised | The American Pancreatic Association diagnostic guideline adapted Cambridge morphology to CT, MRI, ultrasound and MRCP, and placed the grade inside a stepwise evidence framework. | confirmed |
| 1984-07-01 | published | The Cambridge consensus defined the pancreatitis terminology and the ductographic chronic-pancreatitis morphology framework. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/cambridge-pancreatitis · API JSON: https://radcommons.laudos.ai/api/v1/systems/cambridge-pancreatitis · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Fukuoka IPMN — Fukuoka international consensus imaging features for intraductal papillary mucinous neoplasm

> Stratifies pancreatic IPMN by worrisome features and high-risk stigmata on cross-sectional imaging to guide surveillance versus resection.

**Status:** current · **Organ:** Pancreas · **Issuing body:** International Association of Pancreatology · **Version:** 2017 · **Year:** 2017

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI, CT
- Primary source: Tanaka M, Fernandez-Del Castillo C, Kamisawa T, et al.. Revisions of international consensus Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8713311/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| no-risk-features | No worrisome features or high-risk stigmata | Neither high-risk stigmata nor worrisome features present on imaging: a branch-duct IPMN below the worrisome-feature thresholds (cyst <3 cm, no enhancing mural nodule, main pancreatic duct <5 mm, no concerning secondary features). | Imaging surveillance rather than resection; the source describes risk-stratified follow-up of cysts without worrisome features or high-risk stigmata. | Lowest malignancy risk category among IPMN; managed by surveillance. | PMC8713311, Table 2 (revised Fukuoka 2017): absence of the listed worrisome features and high-risk stigmata. | ✓ |
| worrisome-features | Worrisome features | Worrisome features: cyst size >=3 cm; enhancing mural nodule <5 mm; thickened/enhancing cyst walls; main pancreatic duct 5-9 mm; abrupt change in main-duct caliber with distal pancreatic atrophy; lymphadenopathy; elevated serum CA 19-9; acute pancreatitis attributable to the IPMN; and cyst growth rate >5 mm over 2 years. | Further assessment, typically endoscopic ultrasound (EUS), rather than immediate resection; the presence of worrisome features prompts closer evaluation. | Intermediate malignancy risk warranting additional workup. | PMC8713311, Table 2: worrisome features 'Cyst size >= 3 cm; Acute pancreatitis (due to IPMN); Enhancing mural nodule >= 5 mm; Thickened and enhancing cyst wall; MPD dilation 5-9 mm; Abrupt change of MPD caliber with distal pancreatic atrophy; Presence of lymphadenopathy; Elevated serum CA 19-9; Cyst growth rate > 5 mm/2 yr'. | ✓ |
| high-risk-stigmata | High-risk stigmata | High-risk stigmata: obstructive jaundice in a patient with a cystic lesion of the pancreatic head; enhancing mural nodule >=5 mm; main pancreatic duct >=10 mm; (and high-grade dysplasia or cancer on cytology). | Surgical resection is recommended for surgically fit patients with any high-risk stigmata. | Highest malignancy risk category; resection advised. | PMC8713311, Table 2: high-risk stigmata 'Jaundice; Enhancing mural nodule >= 5 mm; MPD >= 10 mm' (plus 'HGD or cancer on cytology'). | ✓ |

### Per-category citations
- **no-risk-features**: Tanaka M, Fernandez-Del Castillo C, Kamisawa T, et al.. Revisions of international consensus Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8713311/ · PMC8713311, Table 2 (revised Fukuoka 2017): absence of the listed worrisome features and high-risk stigmata.
- **worrisome-features**: Tanaka M, Fernandez-Del Castillo C, Kamisawa T, et al.. Revisions of international consensus Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8713311/ · PMC8713311, Table 2: worrisome features 'Cyst size >= 3 cm; Acute pancreatitis (due to IPMN); Enhancing mural nodule >= 5 mm; Thickened and enhancing cyst wall; MPD dilation 5-9 mm; Abrupt change of MPD caliber with distal pancreatic atrophy; Presence of lymphadenopathy; Elevated serum CA 19-9; Cyst growth rate > 5 mm/2 yr'.
- **high-risk-stigmata**: Tanaka M, Fernandez-Del Castillo C, Kamisawa T, et al.. Revisions of international consensus Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas (2017) — https://pmc.ncbi.nlm.nih.gov/articles/PMC8713311/ · PMC8713311, Table 2: high-risk stigmata 'Jaundice; Enhancing mural nodule >= 5 mm; MPD >= 10 mm' (plus 'HGD or cancer on cytology').

## Cross-references
- _shared boundary_ → [ACR Incidental Pancreatic Cyst — ACR incidental pancreatic cyst management](https://radcommons.laudos.ai/systems/acr-incidental-panc-cyst-2017.md) — Two frameworks for managing incidental pancreatic cystic lesions; thresholds for follow-up versus resection differ.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2017-07-01 | revised | International consensus Fukuoka guidelines for IPMN revised (2017). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/fukuoka-ipmn · API JSON: https://radcommons.laudos.ai/api/v1/systems/fukuoka-ipmn · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Modified CTSI (mCTSI) — Modified CT Severity Index for acute pancreatitis

> Contrast-enhanced-CT index that adds pancreatic inflammation (0, 2 or 4), necrosis (0, 2 or 4) and one noncumulative extrapancreatic-complication term (0 or 2) into an even total from 0 to 10. The valid bands are mild 0-2, moderate 4-6 and severe 8-10; it is not the original Balthazar CTSI, does not equal Revised Atlanta clinical severity and cannot select treatment by itself.

**Status:** current · **Organ:** Pancreas · **Issuing body:** Mortele et al. / pancreatitis imaging literature · **Version:** Mortele 2004; imaging timing and clinical-severity boundaries reviewed through 2024 · **Year:** 2004

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Mortele KJ, Wiesner W, Intriere L, et al.. A modified CT severity index for evaluating acute pancreatitis (2004) — https://doi.org/10.2214/ajr.183.5.1831261
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Use the modified-index even totals and its 0-2, 4-6 and 8-10 bands. Require adequate CECT for necrosis, add extrapancreatic complications once, and keep imaging burden separate from Revised Atlanta clinical severity and treatment.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| mild | Mild mCTSI imaging band (0-2) | Mild modified CT Severity Index imaging band: total 0 or 2, displayed as 0-2. Sum one pancreatic-inflammation value (normal 0; intrinsic abnormality with or without peripancreatic inflammatory fat change 2; pancreatic/peripancreatic fluid collection or peripancreatic fat necrosis 4), one CECT necrosis value (none 0; 30% or less 2; more than 30% 4), and a single extrapancreatic-complication term (none 0; one or more qualifying pleural, ascitic, vascular, extrapancreatic-parenchymal or gastrointestinal complications 2). Odd totals are impossible. | Do not order CT or choose treatment merely from a mild band. If the examination was obtained early, note that necrosis may be underestimated; act on the patient's physiology and any individually reported complication. The 2024 ACG guidance reserves CT mainly for uncertain diagnosis or failure to improve after 48-72 hours. | This is the lowest CT-burden band, not a low-risk guarantee or a personalized event probability. Early CECT can underestimate evolving necrosis, and organ failure or another actionable complication remains clinically important regardless of the aggregate total. | Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, modified-index component table and mild 0-2 group; Mikó et al., PMC6718714, Table 1B reproduction of mCTSI components; Banks et al., DOI 10.1136/gutjnl-2012-302779, CECT timing and separate clinical severity; ACG 2024 guideline highlights, imaging recommendation 3. | ✓ |
| moderate | Moderate mCTSI imaging band (4-6) | Moderate modified CT Severity Index imaging band: total 4 or 6, displayed as 4-6. Calculate the same three components with values 0/2/4 for inflammation, 0/2/4 for necrosis and 0/2 once for any number of qualifying extrapancreatic complications. Exactly 30% necrosis remains in the 2-point necrosis bracket. | Use the component findings and current clinical state, not the word moderate, to plan care. Report necrosis extent, collections and each extrapancreatic complication explicitly; decisions about monitoring level, nutrition, antibiotics, drainage, ERCP or intervention require organ failure, infection, timing, anatomy and multidisciplinary context. | The intermediate CT-burden band is associated with worse outcomes than lower scores in cohorts, but it carries no validated patient-specific probability of ICU admission, intervention, organ failure, length of stay or death. Different component combinations can produce the same total. | Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, modified-index component table and moderate 4-6 group; Mikó et al., PMC6718714, Table 1B and pooled discrimination results; ACG 2024 guideline highlights, management recommendations; Revised Atlanta consensus, DOI 10.1136/gutjnl-2012-302779, organ failure and local complications. | ✓ |
| severe | Severe mCTSI imaging band (8-10) | Severe modified CT Severity Index imaging band: total 8 or 10, displayed as 8-10. The total still uses one inflammation value, one necrosis value and a single noncumulative 2-point extrapancreatic-complication term. A total of 7 is not reachable and belongs to neither the modified-index calculation nor its severe band. | Promptly communicate the actual severe imaging features and complications, but do not let the band autonomously prescribe ICU admission, antibiotics, drainage, necrosectomy or surgery. Management follows hemodynamics, organ failure, infection, hemorrhage, obstruction, collection maturity and current multidisciplinary guidance. | This is the highest mCTSI CT-burden band and correlates with worse cohort outcomes. Meta-analytic AUCs describe population-level discrimination and are not an individual's mortality or organ-failure probability; Revised Atlanta severe clinical pancreatitis still requires persistent organ failure rather than an mCTSI threshold. | Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, severe 8-10 group; Mikó et al., DOI 10.3389/fphys.2019.01002, Table 1B and pooled AUC analysis; Banks et al., DOI 10.1136/gutjnl-2012-302779, severe clinical pancreatitis definition; ACG 2024 guideline highlights, management recommendations. | ✓ |

### Per-category citations
- **mild**: Mortele KJ, Wiesner W, Intriere L, et al.. A modified CT severity index for evaluating acute pancreatitis (2004) — https://doi.org/10.2214/ajr.183.5.1831261 · Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, modified-index component table and mild 0-2 group; Mikó et al., PMC6718714, Table 1B reproduction of mCTSI components; Banks et al., DOI 10.1136/gutjnl-2012-302779, CECT timing and separate clinical severity; ACG 2024 guideline highlights, imaging recommendation 3.
- **moderate**: Mortele KJ, Wiesner W, Intriere L, et al.. A modified CT severity index for evaluating acute pancreatitis (2004) — https://doi.org/10.2214/ajr.183.5.1831261 · Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, modified-index component table and moderate 4-6 group; Mikó et al., PMC6718714, Table 1B and pooled discrimination results; ACG 2024 guideline highlights, management recommendations; Revised Atlanta consensus, DOI 10.1136/gutjnl-2012-302779, organ failure and local complications.
- **severe**: Mortele KJ, Wiesner W, Intriere L, et al.. A modified CT severity index for evaluating acute pancreatitis (2004) — https://doi.org/10.2214/ajr.183.5.1831261 · Mortele et al., AJR 2004, DOI 10.2214/ajr.183.5.1831261, severe 8-10 group; Mikó et al., DOI 10.3389/fphys.2019.01002, Table 1B and pooled AUC analysis; Banks et al., DOI 10.1136/gutjnl-2012-302779, severe clinical pancreatitis definition; ACG 2024 guideline highlights, management recommendations.

## Cross-references
- _shared boundary_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — mCTSI is an even-valued 0-10 CECT imaging-burden index with 0-2, 4-6 and 8-10 bands. Revised Atlanta clinical severity depends on organ-failure duration and complications; shared severity words are not a numeric crosswalk.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2024-03-01 | revised | The ACG guideline supplied current CT-timing and management context. It does not turn an mCTSI band into an imaging indication or treatment order. | confirmed |
| 2013-01-01 | revised | The Revised Atlanta consensus established the independent, time-dependent clinical severity and morphology framework used here to prevent a silent mCTSI crosswalk; it did not revise the mCTSI point table. | confirmed |
| 2004-11-01 | published | Mortele and colleagues published the modified CT severity index with three even-valued components and the 0-2, 4-6 and 8-10 imaging bands. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/mortele-ctsi · API JSON: https://radcommons.laudos.ai/api/v1/systems/mortele-ctsi · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# PDAC resectability — Pancreatic ductal adenocarcinoma anatomic resectability classification

> Records a complete, versioned tumor-vessel and metastatic observation vector before assigning resectable, borderline resectable, locally advanced, or metastatic PDAC. Anatomic category is distinct from TNM stage, biologic risk, performance status and operability; it neither guarantees nor permanently excludes resection and cannot choose upfront surgery, neoadjuvant therapy, systemic therapy or palliation without multidisciplinary context.

**Status:** current · **Organ:** Pancreas · **Issuing body:** NCCN / Society of Abdominal Radiology / multidisciplinary pancreatic oncology · **Version:** NCCN-style anatomic criteria reviewed through v2.2025; structured-report and multidisciplinary boundaries through 2026 · **Year:** 2026

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: algorithm
- Logic type: flat
- Modality: CT, MRI
- Primary source: Lee SS, Kim DW, Lee W, Kim KP. Updates on Imaging Assessment of Pancreatic Cancer for Determining Anatomic and Biologic Resectability (2026) — https://pmc.ncbi.nlm.nih.gov/articles/PMC13333231/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Report observations first and the versioned label second. Anatomic resectability, TNM, biology, fitness, actual operability and treatment are separate decisions.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| resectable | Resectable | Under the detailed NCCN-style map reproduced in the 2023 staging review: no solid tumor contact with the celiac axis, superior mesenteric artery or common hepatic artery; and either no SMV/PV contact or contact of 180 degrees or less without venous contour irregularity. The current v2.2025 summary describes no major-artery contact and no major-vein contact or venous abutment without deformity. State the named version and preserve vessel measurements. | Refer to pancreatic multidisciplinary review with pathology, complete staging, biologic risk and patient fitness. Upfront resection with systemic-therapy planning and neoadjuvant approaches can both be valid for selected anatomically resectable PDAC; the label is not an automatic surgery order and does not prove physiologic operability. | This category describes favorable local anatomy under a named convention, not low-risk cancer, cure or guaranteed R0 resection. Recurrence remains common even after margin-negative surgery, and biology, occult disease and condition can outweigh the anatomic label. | Lee et al. 2026, DOI 10.3348/kjr.2026.0341, PMC13333231, Table 1 and treatment-strategy section; Chu and Fishman 2023, DOI 10.1097/JS9.0000000000000899, PMC11486980, Table 1 detailed degree-based thresholds; Moir et al. 2023, PMC11203077, MDT boundary. | ✓ |
| borderline-resectable | Borderline resectable | Under the detailed NCCN-style map: for head/uncinate tumors, common hepatic artery contact without extension to the celiac axis or hepatic bifurcation, SMA contact of 180 degrees or less, or relevant variant-artery contact; for body/tail tumors, celiac-axis contact of 180 degrees or less. Venous criteria include SMV/PV contact over 180 degrees, or 180 degrees or less with contour irregularity or thrombosis, only when suitable proximal and distal vessel permits reconstruction. Current v2.2025 summaries also include reconstructible PV/SMV/IVC deforming abutment or encasement. Version and center convention are mandatory. | Neoadjuvant systemic therapy and later restaging are commonly considered, but regimen, radiation, exploration and vascular reconstruction require expert multidisciplinary assessment of pathology, biology, performance status, response and center capability. Borderline does not itself mandate one regimen or forbid resection. | The anatomy raises technical and margin-positive-resection risk relative to the named resectable group, but it remains a potentially curative-intent category in selected patients. No fixed R0, conversion or survival probability should be attached without a matching cohort and treatment era. | Chu and Fishman 2023, PMC11486980, Table 1 site-specific arterial, venous-degree and reconstructibility criteria; Lee et al. 2026, PMC13333231, Table 1 and borderline/NAT sections; Al-Hawary et al. 2014, DOI 10.1148/radiol.13131184, vessel reporting consensus. | ✓ |
| locally-advanced | Locally advanced (unresectable) | Nonmetastatic locally advanced anatomy under the detailed NCCN-style map includes SMA or celiac-axis contact greater than 180 degrees, body/tail celiac involvement extending to the aorta, or SMV/PV tumor involvement or occlusion that is not reconstructible. The current v2.2025 summary additionally describes extensive major-artery encasement and hepatic-artery involvement extending to the celiac axis or hepatic bifurcation. Reconstructibility is an MDT judgment based on the reported objective anatomy, not a silent CT assumption. | Systemic therapy is commonly the initial backbone; selected patients may later undergo local therapy or conversion-to-resection evaluation at experienced centers. The category does not prescribe a regimen, establish permanent nonoperability or justify omitting restaging after treatment response. | This is extensive local anatomy with lower historical probability of immediate margin-negative resection, not a personal survival estimate or statement of futility. Response, biology, metastasis-free interval, patient condition and technical expertise can change candidacy over time. | Lee et al. 2026, PMC13333231, Table 1 locally advanced criteria and post-NAT section; Chu and Fishman 2023, PMC11486980, Table 1 greater-than-180-degree and unreconstructible-vein thresholds; Moir et al. 2023, PMC11203077, center-dependent resectability and objective vessel reporting. | ✓ |
| metastatic | Metastatic | Definite distant metastatic disease (M1), with every site and evidentiary basis named. Regional nodes remain N stage, while nonregional nodes can be M1. A tiny or otherwise indeterminate liver, lung, peritoneal, nodal, bone or other lesion must remain indeterminate and must not be promoted automatically to metastatic disease. | Multidisciplinary oncology management is usually systemic and goal-directed, with germline/somatic evaluation and symptom-directed procedures when appropriate. The label does not choose a drug regimen, prove that every local intervention is inappropriate, or replace patient goals, performance status and supportive-care assessment. | M1 denotes systemic spread and generally dominates the four-label output, but it is not a fixed individual survival clock or synonym for immediate futility. Preserve metastatic burden, biology, symptoms, treatment response and uncertainty separately. | Lee et al. 2026, PMC13333231, comprehensive distant-staging and treatment context; ACR Appropriateness Criteria revised 2025, locoregional and distant assessment variants; Moir et al. 2023, PMC11203077, template Part A metastatic sites and indeterminate post-treatment findings. | ✓ |

### Per-category citations
- **resectable**: Lee SS, Kim DW, Lee W, Kim KP. Updates on Imaging Assessment of Pancreatic Cancer for Determining Anatomic and Biologic Resectability (2026) — https://pmc.ncbi.nlm.nih.gov/articles/PMC13333231/ · Lee et al. 2026, DOI 10.3348/kjr.2026.0341, PMC13333231, Table 1 and treatment-strategy section; Chu and Fishman 2023, DOI 10.1097/JS9.0000000000000899, PMC11486980, Table 1 detailed degree-based thresholds; Moir et al. 2023, PMC11203077, MDT boundary.
- **borderline-resectable**: Lee SS, Kim DW, Lee W, Kim KP. Updates on Imaging Assessment of Pancreatic Cancer for Determining Anatomic and Biologic Resectability (2026) — https://pmc.ncbi.nlm.nih.gov/articles/PMC13333231/ · Chu and Fishman 2023, PMC11486980, Table 1 site-specific arterial, venous-degree and reconstructibility criteria; Lee et al. 2026, PMC13333231, Table 1 and borderline/NAT sections; Al-Hawary et al. 2014, DOI 10.1148/radiol.13131184, vessel reporting consensus.
- **locally-advanced**: Lee SS, Kim DW, Lee W, Kim KP. Updates on Imaging Assessment of Pancreatic Cancer for Determining Anatomic and Biologic Resectability (2026) — https://pmc.ncbi.nlm.nih.gov/articles/PMC13333231/ · Lee et al. 2026, PMC13333231, Table 1 locally advanced criteria and post-NAT section; Chu and Fishman 2023, PMC11486980, Table 1 greater-than-180-degree and unreconstructible-vein thresholds; Moir et al. 2023, PMC11203077, center-dependent resectability and objective vessel reporting.
- **metastatic**: Lee SS, Kim DW, Lee W, Kim KP. Updates on Imaging Assessment of Pancreatic Cancer for Determining Anatomic and Biologic Resectability (2026) — https://pmc.ncbi.nlm.nih.gov/articles/PMC13333231/ · Lee et al. 2026, PMC13333231, comprehensive distant-staging and treatment context; ACR Appropriateness Criteria revised 2025, locoregional and distant assessment variants; Moir et al. 2023, PMC11203077, template Part A metastatic sites and indeterminate post-treatment findings.

## Cross-references
- _shared boundary_ → [Fukuoka IPMN — Fukuoka international consensus imaging features for intraductal papillary mucinous neoplasm](https://radcommons.laudos.ai/systems/fukuoka-ipmn.md) — Both are pancreatic cross-sectional reporting frameworks, but PDAC resectability maps a suspected or confirmed solid ductal adenocarcinoma and Fukuoka stratifies IPMN. Never apply PDAC vessel-contact labels to a cystic lesion without the correct diagnosis.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-04 | revised | A current radiology review integrated anatomic, biologic and conditional resectability and the post-neoadjuvant fibrosis limitation; it did not create a new universal treatment algorithm. | confirmed |
| 2025-02-13 | revised | NCCN Pancreatic Adenocarcinoma version 2.2025 was the named criteria version used in the current imaging review; the implementation retains objective vessel observations because criteria and center capability can change. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/panc-ca-resectability · API JSON: https://radcommons.laudos.ai/api/v1/systems/panc-ca-resectability · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Revised Atlanta — Revised Atlanta classification of acute pancreatitis

> Time-dependent acute-pancreatitis framework separating the clinical three-grade severity axis from interstitial versus necrotizing morphology and four collection types. Diagnosis requires two of three clinical, laboratory or imaging criteria; organ-failure duration must be reassessed before severity is finalized, and the classification itself is not a treatment guideline.

**Status:** current · **Organ:** Pancreas · **Issuing body:** Acute Pancreatitis Classification Working Group · **Version:** 2012 consensus (published 2013); 2024 ACG care context · **Year:** 2013

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI, US
- Primary source: Banks PA, Bollen TL, Dervenis C, et al.. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus (2013) — https://naspghan.org/files/documents/pdfs/training/curriculum-resources/pancreatic-disease/Banks_Classification_of_acute_pancreatitis-2012_revision_of_the_Atlantal_classification_and_definitions_by_international_consensus.pdf
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Confirm acute pancreatitis with the two-of-three gate, classify clinical severity dynamically from organ failure and complications, and report morphology on independent axes. The consensus standardizes definitions and does not itself prescribe treatment.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| mild | Mild, no organ failure or complications | Confirmed acute pancreatitis with no modified-Marshall organ failure and no local or systemic complication. Diagnosis first requires at least two of three: characteristic acute epigastric pain, lipase or amylase at least three times the upper limit of normal, or characteristic CT, MRI or ultrasound findings. Time the episode from pain onset, not admission, and report morphology separately. | The Revised Atlanta consensus defines this category but is not a treatment guideline. In current ACG context, begin a low-fat solid oral diet within 24-48 hours as tolerated, use individualized early monitoring and lactated-Ringer-based fluid care, avoid prophylactic antibiotics, and investigate etiology. Do not obtain admission CT solely to prove pancreatitis when pain and enzymes already satisfy the diagnostic gate. | This is the most favorable consensus category and mortality is described as rare. That statement is population-level rather than a zero-risk guarantee; etiology, age, comorbidity, hemodynamics and subsequent evolution remain important, and a later complication or organ failure can increase the recorded maximum severity. | Banks et al. Gut 2013, DOI 10.1136/gutjnl-2012-302779, Diagnosis of acute pancreatitis, Definition of onset and Grades of severity; Tenner et al. ACG 2024, DOI 10.14309/ajg.0000000000002645, official highlights for early oral feeding, fluids, antibiotics and CT timing. | ✓ |
| moderately-severe | Moderately severe | Confirmed acute pancreatitis with transient organ failure resolving in less than 48 hours and/or at least one local or systemic complication, but without persistent organ failure beyond 48 hours. Organ failure is a modified Marshall score of at least 2 in the respiratory, cardiovascular or renal system. Name every complication and separately classify interstitial versus necrotizing morphology and each collection as APFC, pseudocyst, ANC or WON. | Provide close clinical and organ-function reassessment, including the 48-hour duration boundary, and treat the actual complication rather than the label. Current ACG context favors enteral nutrition when oral intake is not tolerated, avoids parenteral nutrition when feasible and reserves CT or MRI for diagnostic uncertainty or failure to improve at 48-72 hours. Cholangitis, infected necrosis, obstruction or symptomatic collections follow their own clinical pathways. | Morbidity and mortality are higher than in mild disease but lower than in severe disease at the population level; the code supplies no calibrated individual probability. A patient with a local complication but no organ failure and one with transient organ failure share the category but not necessarily the same course, so retain the qualifying features and serial physiology. | Banks et al. 2013 consensus, Definitions of organ failure, local/systemic complications and moderately severe acute pancreatitis; morphological sections for APFC, pseudocyst, ANC and WON; Tenner et al. 2024 official ACG highlights for imaging, enteral nutrition and complication-led care. | ✓ |
| severe | Severe, persistent organ failure | Confirmed acute pancreatitis with persistent organ failure continuing for more than 48 hours in one or more modified-Marshall systems, whether or not local or systemic complications are present. Before that duration is known, report potentially severe or provisional severity and reassess rather than prematurely finalizing moderate versus severe. Preserve organ-specific scores and timestamps. | Escalate organ-support and multidisciplinary care according to physiology, not the adjective alone. Use enteral feeding when feasible, evaluate suspected infection without prophylactic antibiotics, perform urgent ERCP when concomitant cholangitis provides the indication, and in a stable patient delay intervention for pancreatic necrosis approximately 4-6 weeks when clinically feasible. Hemodynamic instability, infection and other complications can require earlier action independent of collection maturity. | Persistent organ failure is the highest-risk Atlanta category. The original consensus cited approximately 36-50 percent mortality for early persistent organ failure in historical cohorts, but this is not a current bedside probability or treatment threshold. Risk varies with the number of failed organs, trajectory, infection, age, comorbidity and quality of supportive care. | Banks et al. 2013 consensus, persistent organ failure and severe acute pancreatitis definitions plus historical early-phase mortality context; Tenner et al. 2024 ACG official highlights for organ-support setting, enteral nutrition, infection, cholangitis-associated ERCP and delayed stable-necrosis intervention. | ✓ |

### Per-category citations
- **mild**: Banks PA, Bollen TL, Dervenis C, et al.. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus (2013) — https://naspghan.org/files/documents/pdfs/training/curriculum-resources/pancreatic-disease/Banks_Classification_of_acute_pancreatitis-2012_revision_of_the_Atlantal_classification_and_definitions_by_international_consensus.pdf · Banks et al. Gut 2013, DOI 10.1136/gutjnl-2012-302779, Diagnosis of acute pancreatitis, Definition of onset and Grades of severity; Tenner et al. ACG 2024, DOI 10.14309/ajg.0000000000002645, official highlights for early oral feeding, fluids, antibiotics and CT timing.
- **moderately-severe**: Banks PA, Bollen TL, Dervenis C, et al.. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus (2013) — https://naspghan.org/files/documents/pdfs/training/curriculum-resources/pancreatic-disease/Banks_Classification_of_acute_pancreatitis-2012_revision_of_the_Atlantal_classification_and_definitions_by_international_consensus.pdf · Banks et al. 2013 consensus, Definitions of organ failure, local/systemic complications and moderately severe acute pancreatitis; morphological sections for APFC, pseudocyst, ANC and WON; Tenner et al. 2024 official ACG highlights for imaging, enteral nutrition and complication-led care.
- **severe**: Banks PA, Bollen TL, Dervenis C, et al.. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus (2013) — https://naspghan.org/files/documents/pdfs/training/curriculum-resources/pancreatic-disease/Banks_Classification_of_acute_pancreatitis-2012_revision_of_the_Atlantal_classification_and_definitions_by_international_consensus.pdf · Banks et al. 2013 consensus, persistent organ failure and severe acute pancreatitis definitions plus historical early-phase mortality context; Tenner et al. 2024 ACG official highlights for organ-support setting, enteral nutrition, infection, cholangitis-associated ERCP and delayed stable-necrosis intervention.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2024-03-01 | revised | The ACG published current acute-pancreatitis management guidance used here as care context; it does not alter the Revised Atlanta severity codes or collection definitions. | confirmed |
| 2013-01-01 | revised | Revised Atlanta classification published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/atlanta-pancreatitis · API JSON: https://radcommons.laudos.ai/api/v1/systems/atlanta-pancreatitis · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Graf — Graf ultrasound classification of developmental dysplasia of the hip

> Per-hip infant ultrasound classification combining a valid standard plane, bony-roof morphology and alpha angle, cartilaginous-roof morphology and beta angle, chronological age, and stress behavior where indicated.

**Status:** current · **Organ:** Pediatric · **Issuing body:** Graf · **Version:** complete subtype model · **Year:** 1984

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify each hip only from a valid standard plane and return the most specific supported code. Parent codes preserve compatibility and make missing subtype inputs explicit instead of turning uncertainty into a false Ia/Ib, IIa+/IIa-, IIc stability, or IIIa/IIIb assignment.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, mature (subtype unresolved) | Mature parent type on a technically valid standard-plane examination: alpha angle at least 60 degrees, good bony roof, and cartilaginous roof covering the femoral head. Use parent I when beta is unavailable or unreliable, rather than guessing Ia or Ib. | A mature Type I label does not generate a brace or procedure recommendation. Continue the age- and risk-appropriate clinical surveillance program; if the examination or beta measurement is technically inadequate, repeat the ultrasound rather than forcing a subtype. | Type I is morphologically mature and is not a numeric zero-risk guarantee. The code does not replace the clinical hip examination or eliminate follow-up that is indicated by instability, risk factors, or the local screening pathway. | Graf 1984, PMID 6392336 (normal according to age as the first basic category); Graf 2006, Table 6.1 (Type I alpha >=60 and mature morphology); AAOS 2014 guideline, Summary recommendations on surveillance after a normal infant hip examination. | ✓ |
| Ia | Type Ia, mature with long cartilaginous-roof coverage | Mature hip with alpha angle at least 60 degrees and beta angle at or below 55 degrees, good bony roof, angular bony rim, and cartilaginous roof extending well over the femoral head. | No type-directed treatment follows from Ia. Preserve side and measurements, and use routine clinical surveillance or risk-factor imaging only when otherwise indicated. | Ia is a mature morphology, not a calibrated probability of future dysplasia. A technically invalid plane or discordant clinical instability must override reassurance from a copied angle value. | Graf 2006, Table 6.1 and Chapter 8 beta-value discussion (Type Ia, alpha >=60, beta threshold 55, long cartilage-roof coverage); Graf 1984, PMID 6392336. | ✓ |
| Ib | Type Ib, mature with shorter cartilaginous-roof coverage | Mature hip with alpha angle at least 60 degrees and beta angle above 55 degrees, good bony roof, a blunt or slightly rounded bony rim, and shorter cartilaginous-roof coverage than Ia. Ib remains a mature Type I hip. | Do not treat Ib as dysplasia solely because beta exceeds 55 degrees. Record the mature type and use the clinical examination and screening context for any follow-up decision. | The Ia/Ib distinction describes cartilage-roof geometry and is not an ordinal risk or treatment scale. Ib does not by itself predict instability or adverse outcome. | Graf 2006, Table 6.1 and Chapter 8 (Type Ib alpha >=60, beta >55, shorter cartilage-roof coverage); Graf 1984, PMID 6392336. | ✓ |
| IIa | Type IIa, physiologically immature (subtype unresolved) | Centered, physiologically immature parent type in the first 12 weeks: alpha 50-59 degrees, deficient but potentially age-appropriate bony roof, rounded rim, and cartilage roof covering the femoral head. Use parent IIa before week 6 or when the age-specific maturation curve cannot be applied. | Document chronological age and arrange age-appropriate clinical and sonographic follow-up. A static IIa label alone does not justify automatic bracing; clinical stability, maturation trajectory and pediatric orthopaedic assessment determine the plan. | Many immature hips mature, but parent IIa does not state whether maturation is on schedule. Without age trajectory and stability, it cannot provide a patient-specific persistence or dislocation probability. | Graf 2006, Table 6.1 and Section 8.1.1 (Type IIa alpha 50-59, age 0-12 weeks, no +/- differentiation before week 6); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities. | ✓ |
| IIa+ | Type IIa+, age-appropriate maturation | Centered physiologically immature hip from week 6 through week 12 with alpha 50-59 degrees at or above the age-specific minimum Graf maturation curve toward alpha 60 by week 12. At week 6, alpha 55 degrees or more is the published example. | Track maturation to a mature Type I endpoint with the clinically appropriate interval. Observation is an option for a clinically stable morphologic abnormality under the AAOS guideline; the code does not set a universal scan interval or brace decision. | IIa+ means the measured bony maturation is age appropriate within the Graf model, not that normalization or long-term outcome is guaranteed. Instability and technical error remain separate concerns. | Graf 2006, Section 8.1.1 and maturation curve (IIa+ at or above the minimum linear maturation path; week-6 example alpha >=55); AAOS 2014 guideline, stable morphologic abnormality and surveillance recommendations. | ✓ |
| IIa- | Type IIa-, maturational deficit | Centered physiologically immature hip after week 6 and through week 12 with alpha 50-59 degrees below the age-specific minimum Graf maturation curve. At week 6, alpha below 55 but at least 50 degrees is the published example. | Flag a maturational deficit for prompt pediatric orthopaedic review and documented follow-up. Do not prescribe a brace from the code alone; combine age, stability, serial change, clinical examination and specialist judgment. | IIa- identifies lagging maturation and greater concern than IIa+, but it is not a calibrated dislocation, residual-dysplasia or treatment-failure probability. | Graf 2006, Section 8.1.1 (IIa- below the minimum linear maturation curve; do not distinguish before week 6); AAOS 2014 guideline, clinical stability and treatment-of-instability recommendations. | ✓ |
| IIb | Type IIb, delayed ossification after 12 weeks | Centered hip after 12 weeks with alpha 50-59 degrees, deficient bony roof, rounded rim, and cartilage roof still covering the femoral head. The same angle range that can be physiologically immature earlier is dysplastic or delayed for this age. | Flag IIb for pediatric orthopaedic assessment and an explicit management plan. The type identifies age-inappropriate ossification but does not independently select observation, bracing or another intervention. | IIb represents persistent age-inappropriate acetabular development, but Graf type alone does not quantify residual dysplasia, progression, treatment response or long-term outcome. | Graf 2006, Table 6.1 and Section 8.1.1 (Type IIb alpha 50-59 after 12 weeks, dysplastic); AAOS 2014 guideline limitations and individualized-care disclaimer. | ✓ |
| IIc | Type IIc, critical centered hip (stability unresolved) | Critical but centered parent type at rest: alpha 43-49 degrees, severely deficient bony roof, rounded-to-flat rim, cartilage roof still covering the femoral head, and resting beta at or below the 77-degree separation boundary. Use parent IIc when a valid stress result is unavailable. | Flag the severely deficient centered hip for prompt specialist assessment and document that stability is unresolved. Do not infer stable or unstable or choose treatment from the static image alone. | IIc is close to decentering in the Graf morphology, but without stress assessment it does not determine whether pathological instability is present or supply a numeric dislocation risk. | Graf 2006, Table 6.1, Sections 8.1-8.2 and Chapter 9 (IIc alpha 43-49, beta <77, centered; stress distinguishes stable from unstable); Graf 1984, PMID 6392336. | ✓ |
| IIc-stable | Type IIc stable | A resting Type IIc hip that remains centered during a valid stress examination and does not convert to Type D. Resting morphology remains alpha 43-49 degrees and beta at or below the 77-degree separation boundary. | Prompt pediatric orthopaedic evaluation remains appropriate because the bony roof is severely deficient. Clinical stability may support observation in selected infants under limited AAOS evidence, but the complete age, examination and follow-up context governs care. | Stable refers to the observed stress behavior, not a benign or zero-risk state. The severe acetabular deficiency remains and the classification does not quantify persistence or later dysplasia. | Graf 2006, Section 9.2.2 (IIc stable when stress does not alter the type); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities. | ✓ |
| IIc-unstable | Type IIc unstable | A hip that is Type IIc at rest but becomes Type D during a valid stress examination, with pathological decentering and beta rising above 77 degrees under pressure. | Communicate pathological instability promptly for pediatric orthopaedic management. AAOS supports immediate or delayed brace treatment as options for a positive instability examination based on limited evidence, but device, timing and monitoring are clinician decisions. | IIc-unstable documents demonstrable pathological instability and risk of decentering; it is not a calibrated probability of failed bracing, surgery or residual dysplasia. | Graf 2006, Figure 9.2 and Section 9.2.2 (resting IIc converts to D under stress); AAOS 2014 guideline, treatment of clinical instability and serial monitoring during brace treatment. | ✓ |
| D | Type D, decentering at rest | Decentering hip at rest with alpha 43-49 degrees and beta above 77 degrees, severely deficient bony roof, rounded-to-flat rim, and displaced cartilage roof. Use D, not IId. | Treat the resting decentering finding as a prompt pediatric orthopaedic referral and report centering, reducibility or stress behavior when safely assessed. The code does not select the reduction or retention method. | D is already decentered at rest and therefore more urgent than a centered IIc morphology, but it supplies no patient-specific treatment-success or complication percentage. | Graf 2006, Figure 8.3, Table 6.1 and Chapter 9 (D alpha 43-49, beta >77, decentering; explicit rejection of the IId label); AAOS 2014 guideline. | ✓ |
| III | Type III, decentered (subtype unresolved) | Decentered parent Type III hip with alpha below 43 degrees, poor bony roof, flattened rim, and cartilage roof pressed cranially. Use parent III when cartilage-roof echogenicity is not adequately documented. | Communicate a decentered hip promptly and obtain pediatric orthopaedic management. Do not infer IIIa or IIIb or prescribe a reduction strategy when the cartilage subtype or clinical context is missing. | Type III denotes advanced decentering, not a numeric prognosis. Parent III does not state whether structural cartilage alteration is present and cannot quantify reduction success, osteonecrosis or later dysplasia. | Graf 2006, Table 6.1 (Type III alpha <43, poor roof, cranially displaced cartilage) and Chapter 9 resting-position rule; Graf 1984, PMID 6392336. | ✓ |
| IIIa | Type IIIa, no structural cartilage alteration | Decentered Type III hip with alpha below 43 degrees and cartilage roof pressed cranially without structural alteration, appearing hypoechoic or without internal echoes relative to the altered IIIb pattern. | Report the decentered hip and preserved cartilage echotexture as separate facts and obtain prompt pediatric orthopaedic management. IIIa does not by itself choose a device, reduction method or operation. | Absence of the IIIb echogenic structural alteration does not make a Type III hip stable or low risk. The subtype is morphologic and not a calibrated outcome prediction. | Graf 2006, Table 6.1 (IIIa alpha <43, cranially pressed cartilage without structural alteration); complete subtype table reproduced in PMC3965765. | ✓ |
| IIIb | Type IIIb, structural cartilage alteration | Decentered Type III hip with alpha below 43 degrees and cartilage roof pressed cranially with structural alteration, manifested by abnormal echogenicity. | Report the structural cartilage alteration and decentering explicitly and obtain prompt pediatric orthopaedic management. The code is not an autonomous treatment instruction. | IIIb records altered cartilage morphology in an already decentered hip, but the classification does not provide an individual probability of reduction failure, osteonecrosis, surgery or residual dysplasia. | Graf 2006, Table 6.1 (IIIb alpha <43, cranially pressed echogenic cartilage with structural alteration); complete subtype table reproduced in PMC3965765. | ✓ |
| IV | Type IV, severe decentering with caudally displaced cartilage roof | Severely decentered Type IV hip with poor bony roof, flattened rim, alpha below 43 degrees, and cartilage roof pressed caudally; the proximal perichondrium is horizontal or dips caudally. | Communicate the severe decentering urgently for pediatric orthopaedic management and describe reducibility only when appropriately assessed. Type IV does not independently prescribe closed reduction, casting or surgery. | Type IV is the most severely displaced morphology in the Graf map, but the label is not a calibrated probability of treatment failure, osteonecrosis, surgery or long-term impairment. | Graf 2006, Table 6.1 (Type IV alpha <43, poor roof and caudally pressed cartilage roof); Graf 1984, PMID 6392336; AAOS 2014 guideline individualized-care disclaimer. | ✓ |

### Per-category citations
- **I**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 1984, PMID 6392336 (normal according to age as the first basic category); Graf 2006, Table 6.1 (Type I alpha >=60 and mature morphology); AAOS 2014 guideline, Summary recommendations on surveillance after a normal infant hip examination.
- **Ia**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 and Chapter 8 beta-value discussion (Type Ia, alpha >=60, beta threshold 55, long cartilage-roof coverage); Graf 1984, PMID 6392336.
- **Ib**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 and Chapter 8 (Type Ib alpha >=60, beta >55, shorter cartilage-roof coverage); Graf 1984, PMID 6392336.
- **IIa**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 and Section 8.1.1 (Type IIa alpha 50-59, age 0-12 weeks, no +/- differentiation before week 6); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities.
- **IIa+**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Section 8.1.1 and maturation curve (IIa+ at or above the minimum linear maturation path; week-6 example alpha >=55); AAOS 2014 guideline, stable morphologic abnormality and surveillance recommendations.
- **IIa-**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Section 8.1.1 (IIa- below the minimum linear maturation curve; do not distinguish before week 6); AAOS 2014 guideline, clinical stability and treatment-of-instability recommendations.
- **IIb**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 and Section 8.1.1 (Type IIb alpha 50-59 after 12 weeks, dysplastic); AAOS 2014 guideline limitations and individualized-care disclaimer.
- **IIc**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1, Sections 8.1-8.2 and Chapter 9 (IIc alpha 43-49, beta <77, centered; stress distinguishes stable from unstable); Graf 1984, PMID 6392336.
- **IIc-stable**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Section 9.2.2 (IIc stable when stress does not alter the type); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities.
- **IIc-unstable**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Figure 9.2 and Section 9.2.2 (resting IIc converts to D under stress); AAOS 2014 guideline, treatment of clinical instability and serial monitoring during brace treatment.
- **D**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Figure 8.3, Table 6.1 and Chapter 9 (D alpha 43-49, beta >77, decentering; explicit rejection of the IId label); AAOS 2014 guideline.
- **III**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 (Type III alpha <43, poor roof, cranially displaced cartilage) and Chapter 9 resting-position rule; Graf 1984, PMID 6392336.
- **IIIa**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 (IIIa alpha <43, cranially pressed cartilage without structural alteration); complete subtype table reproduced in PMC3965765.
- **IIIb**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 (IIIb alpha <43, cranially pressed echogenic cartilage with structural alteration); complete subtype table reproduced in PMC3965765.
- **IV**: Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia (1984) — https://pubmed.ncbi.nlm.nih.gov/6392336/ · Graf 2006, Table 6.1 (Type IV alpha <43, poor roof and caudally pressed cartilage roof); Graf 1984, PMID 6392336; AAOS 2014 guideline individualized-care disclaimer.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1984-11-01 | published | Graf described four basic sonographic categories for infant hip dysplasia and established ultrasound as a screening and classification method. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/graf-ddh · API JSON: https://radcommons.laudos.ai/api/v1/systems/graf-ddh · Agent index: https://radcommons.laudos.ai/llms.txt

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# Herring — Modified Herring lateral pillar classification of Legg-Calve-Perthes disease

> Per-hip prognostic morphology assigned only on a technically adequate true AP radiograph during the fragmentation stage. The modified system separates A, B, B/C border and C by lateral-pillar height and ossification; age at onset remains an independent input, and the code alone neither diagnoses disease nor prescribes or excludes containment treatment.

**Status:** current · **Organ:** Pediatric · **Issuing body:** Herring et al. / Legg-Calve-Perthes Study Group · **Version:** 1992 original; modified four-group system and outcome study 2004; current POSNA care boundary · **Year:** 1992

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Kollitz KM, Gee AO. Classifications in Brief: The Herring Lateral Pillar Classification for Legg-Calve-Perthes Disease (2013) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3676599/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify one hip only on an adequate true AP view during fragmentation. Preserve the raw height and B/C morphology, age at onset, timing and uncertainty; use the code as a historical prognostic descriptor, never as an autonomous treatment rule.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Group A | Modified Herring group A: on an adequate true AP radiograph during the fragmentation stage, the lateral pillar is uninvolved and retains full height without the density or ossification change that defines involvement. Classify each hip and timepoint separately. | The Herring group alone does not select treatment. Group A had uniformly favorable skeletal-maturity morphology in the multicenter cohort, but current care still integrates age at onset, stage, extrusion, range of motion, symptoms and containment; do not use A as an automatic discharge or no-follow-up rule. | In the published modified-classification outcome table, 100% of group-A hips reached Stulberg I or II at skeletal maturity. This historical cohort distribution is a group-level prognostic descriptor, not a guaranteed individual outcome. | Herring et al. 2004 Part I, PMID 15466719 and DOI 10.2106/00004623-200410000-00001, modified classification; Kollitz and Gee 2013, PMC3676599, Table 2, group A criteria and Stulberg distribution; POSNA LCP Study Guide, current multifactorial care context. | ✓ |
| B | Group B | Modified Herring group B: during fragmentation, more than 50% of lateral-pillar height is retained and none of the B/C border morphologies (thin or narrow pillar, poor ossification, or depression to about exactly one-half height) is present. | Age modifies the treatment evidence. In the 2004 prospective study, group-B hips with onset after age 8 had better outcomes after operative containment, whereas group-B hips with onset at age 8 or younger did similarly well with operative and nonoperative care. This does not create an automatic osteotomy rule: current decisions also require stage, extrusion, motion, containment feasibility and specialist judgment. | The multicenter outcome table reported 67% Stulberg I or II, 27% Stulberg III and 6% Stulberg IV or V for group B. Age at onset is an independent prognostic input, so these pooled historical proportions are not personal probabilities. | Kollitz and Gee 2013, PMC3676599, Table 2, group B >50% height and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720 and DOI 10.2106/00004623-200410000-00002, age-stratified operative versus nonoperative results; POSNA LCP Study Guide, current containment context. | ✓ |
| B/C | Group B/C border | Modified Herring B/C border group: the fragmented lateral pillar is at or above the one-half-height boundary but has a border morphology—more than half height with a thin or narrow pillar, at least about half height with poor ossification, or depression to about exactly 50% of the central-pillar height. Do not hard-code the conflicting millimetre/centimetre width rendered in secondary sources. | In the prospective multicenter cohort, B/C hips with onset after age 8 had better outcomes with operative containment. The finding is age- and cohort-specific, not a grade-only prescription; current planning also depends on early timing, extrusion, range of motion, skeletal maturity, containment feasibility and patient-specific orthopedic assessment. | The published table reported 28% Stulberg I or II, 43% Stulberg III and 30% Stulberg IV or V for B/C (rounding totals approximately 101%). This is an intermediate historical group distribution and not an individualized probability. | Herring et al. 2004 Part I, PMID 15466719, modified B/C morphologies and reliability; Kollitz and Gee 2013, PMC3676599, Tables 1-2, B/C criteria and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720, age-treatment interaction. | ✓ |
| C | Group C | Modified Herring group C: less than 50% of lateral-pillar height is retained during the fragmentation stage. Exactly one-half belongs at the B/C boundary rather than C; if image quality cannot resolve that boundary, return uncertainty instead of rounding. | Group C had the least favorable outcomes and no demonstrated operative-versus-nonoperative difference in the 2004 cohort. That result does not make C a no-treatment or futility label: current care remains individualized around age, stage, symptoms, extrusion, motion, containment feasibility and later reconstructive or salvage needs. | The published table reported 13% Stulberg II, 52% Stulberg III and 35% Stulberg IV or V for group C. These historical skeletal-maturity outcomes describe a cohort and must not be used as a deterministic disability or treatment forecast. | Kollitz and Gee 2013, PMC3676599, Table 2, group C <50% height and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720 and DOI 10.2106/00004623-200410000-00002, least-favorable results and no demonstrated treatment difference; POSNA LCP Study Guide, current individualized care context. | ✓ |

### Per-category citations
- **A**: Kollitz KM, Gee AO. Classifications in Brief: The Herring Lateral Pillar Classification for Legg-Calve-Perthes Disease (2013) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3676599/ · Herring et al. 2004 Part I, PMID 15466719 and DOI 10.2106/00004623-200410000-00001, modified classification; Kollitz and Gee 2013, PMC3676599, Table 2, group A criteria and Stulberg distribution; POSNA LCP Study Guide, current multifactorial care context.
- **B**: Kollitz KM, Gee AO. Classifications in Brief: The Herring Lateral Pillar Classification for Legg-Calve-Perthes Disease (2013) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3676599/ · Kollitz and Gee 2013, PMC3676599, Table 2, group B >50% height and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720 and DOI 10.2106/00004623-200410000-00002, age-stratified operative versus nonoperative results; POSNA LCP Study Guide, current containment context.
- **B/C**: Kollitz KM, Gee AO. Classifications in Brief: The Herring Lateral Pillar Classification for Legg-Calve-Perthes Disease (2013) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3676599/ · Herring et al. 2004 Part I, PMID 15466719, modified B/C morphologies and reliability; Kollitz and Gee 2013, PMC3676599, Tables 1-2, B/C criteria and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720, age-treatment interaction.
- **C**: Kollitz KM, Gee AO. Classifications in Brief: The Herring Lateral Pillar Classification for Legg-Calve-Perthes Disease (2013) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3676599/ · Kollitz and Gee 2013, PMC3676599, Table 2, group C <50% height and Stulberg distribution; Herring et al. 2004 Part II, PMID 15466720 and DOI 10.2106/00004623-200410000-00002, least-favorable results and no demonstrated treatment difference; POSNA LCP Study Guide, current individualized care context.

## Cross-references
- _shared boundary_ → [Graf — Graf ultrasound classification of developmental dysplasia of the hip](https://radcommons.laudos.ai/systems/graf-ddh.md) — Both are pediatric hip systems: Graf screens the infant hip on ultrasound, Herring prognosticates Legg-Calve-Perthes on radiographs.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2004-10-01 | revised | The prospective multicenter study published the modified four-group A, B, B/C and C system, formal reliability testing and age-stratified outcome evidence. | confirmed |
| 2004-01-01 | revised | Modified lateral pillar classification adds the B/C border group. | confirmed |
| 1992-01-01 | published | Herring and colleagues introduced the three-group lateral-pillar classification for Legg-Calve-Perthes disease during fragmentation. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/herring-lcp · API JSON: https://radcommons.laudos.ai/api/v1/systems/herring-lcp · Agent index: https://radcommons.laudos.ai/llms.txt

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# Papile — Papile grading of germinal matrix and intraventricular hemorrhage

> Grades germinal matrix and intraventricular hemorrhage in neonates.

**Status:** current · **Organ:** Pediatric · **Issuing body:** Neonatal imaging consensus · **Version:** 1978 · **Year:** 1978

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage (Papile) (1978) — https://doi.org/10.1016/s0022-3476(78)80282-0
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | Hemorrhage limited to the germinal matrix (subependymal), without extension into the ventricle. | Supportive neonatal care; serial cranial ultrasound surveillance is advised (roughly weekly for about four weeks and again at discharge) with head-circumference monitoring; no CSF diversion needed in the absence of ventricular dilatation. | Low-grade injury but not benign: cerebral palsy reported in roughly 7-8% at 2 years corrected age, and neurodevelopmental delay, hearing loss and CP can still occur. | Criteria: StatPearls NBK538310, Introduction. Management/risk: Inan/Karadag review (PMC7536465) — CP ~6.8% in grade I, weekly US surveillance for grades I-II. | ✓ |
| II | Grade II | Intraventricular hemorrhage occupying less than 50% of the ventricular area, without ventricular dilatation. | Supportive care with serial cranial ultrasound (about weekly for four weeks and at discharge) and head-circumference tracking; intervention reserved for any progressive ventricular dilatation. | Cerebral palsy reported in about 8% at 2 years, rising to ~12% when accompanied by ventricular dilatation or cystic/echodense periventricular leukomalacia. | Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — CP ~8.1% (12.2% with ventricular dilatation/PVL); weekly US surveillance for grades I-II. | ✓ |
| III | Grade III | Intraventricular hemorrhage with ventricular dilatation, the blood occupying more than 50% of the ventricle. | Closer cranial ultrasound surveillance (about twice weekly until discharge); for progressive post-hemorrhagic ventricular dilatation, temporizing CSF measures (ventricular reservoir or ventriculosubgaleal shunt) precede permanent ventriculoperitoneal shunting once the infant reaches ~2-2.5 kg. | Severe (grade III/IV) IVH: post-hemorrhagic hydrocephalus develops in roughly a third of very-low-birth-weight infants with IVH; cerebral palsy exceeds 50% and ~75% need special education in grade III-IV. | Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — twice-weekly US, reservoir/subgaleal shunt then VP shunt; PHH in ~1/3, CP >50% and special education ~75% in grade III-IV. | ✓ |
| IV | Grade IV | Intraventricular hemorrhage accompanied by intraparenchymal (periventricular) hemorrhage; previously termed Grade IV, now also called periventricular hemorrhagic infarction (PVHI). | Intensive cranial ultrasound surveillance (about twice weekly until discharge); progressive PHVD managed with temporizing CSF drainage (reservoir/ventriculosubgaleal shunt) and later permanent VP shunting; supportive care with seizure management. | Worst prognosis: roughly 30-40% die; severe neurodevelopmental disorder in ~55% (rising to ~86% with PVHI plus shunt); reported cerebral palsy ~60%, cognitive problems ~50%, visual field defects ~25%, epilepsy ~20%. | Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — mortality ~30-40%, severe NDD ~55% (86% with PVHI+shunt), CP ~60%, cognitive ~50%, visual defects ~25%, epilepsy ~20%. | ✓ |

### Per-category citations
- **I**: Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage (Papile) (1978) — https://doi.org/10.1016/s0022-3476(78)80282-0 · Criteria: StatPearls NBK538310, Introduction. Management/risk: Inan/Karadag review (PMC7536465) — CP ~6.8% in grade I, weekly US surveillance for grades I-II.
- **II**: Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage (Papile) (1978) — https://doi.org/10.1016/s0022-3476(78)80282-0 · Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — CP ~8.1% (12.2% with ventricular dilatation/PVL); weekly US surveillance for grades I-II.
- **III**: Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage (Papile) (1978) — https://doi.org/10.1016/s0022-3476(78)80282-0 · Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — twice-weekly US, reservoir/subgaleal shunt then VP shunt; PHH in ~1/3, CP >50% and special education ~75% in grade III-IV.
- **IV**: Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage (Papile) (1978) — https://doi.org/10.1016/s0022-3476(78)80282-0 · Criteria: StatPearls NBK538310, Introduction. Management/risk: PMC7536465 — mortality ~30-40%, severe NDD ~55% (86% with PVHI+shunt), CP ~60%, cognitive ~50%, visual defects ~25%, epilepsy ~20%.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/papile-ivh · API JSON: https://radcommons.laudos.ai/api/v1/systems/papile-ivh · Agent index: https://radcommons.laudos.ai/llms.txt

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# PI-RADS — Prostate Imaging Reporting and Data System v2.1

> Assessment of clinically significant prostate cancer likelihood on multiparametric MRI, with the dominant sequence depending on zone.

**Status:** current · **Organ:** Prostate · **Issuing body:** ACR, ESUR, AdMeTech · **Version:** v2.1 · **Year:** 2019

## Provenance and currency
- Family: lexicon
- Logic type: matrix
- Modality: MRI
- Primary source: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Use DWI/ADC as the dominant sequence in the peripheral zone and T2W in the transition zone. DCE only upgrades a peripheral-zone DWI score 3 to overall category 4 when positive; category and clinical management are separate decisions.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Very low likelihood of clinically significant cancer | Very low likelihood. With diagnostic sequences, a peripheral-zone lesion maps here when DWI/ADC score is 1; a transition-zone finding maps here when T2W score is 1, meaning a normal-appearing transition zone or a round completely encapsulated typical nodule. | PI-RADS v2.1 says biopsy should not be based on category 1 alone, but it does not prescribe management. Final action must incorporate PSA and other laboratory data, clinical history, examination, local expertise, and standards of care. | Clinically significant prostate cancer is highly unlikely to be present. This is a qualitative imaging likelihood, not a numeric patient-level probability or guarantee of absence. | ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; assessment-category meaning and management-scope paragraph p 10. | ✓ |
| 2 | Low | Low likelihood. In the peripheral zone, DWI/ADC score 2 determines overall category 2. In the transition zone, T2W score 2 remains category 2 when DWI/ADC is 3 or lower; T2W score 2 with DWI/ADC 4 or 5 instead upgrades to category 3. | PI-RADS v2.1 says biopsy should not be based on category 2 alone, but it does not prescribe management. A clinically discordant negative MRI still requires patient-level assessment rather than automatic reassurance. | Clinically significant prostate cancer is unlikely to be present. The category reflects mpMRI appearance only and must not absorb PSA, digital rectal examination, history, or treatment plans. | ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; transition-zone matrix p 11 and management-scope paragraph p 10. | ✓ |
| 3 | Intermediate, equivocal | Intermediate or equivocal likelihood. In the peripheral zone, DWI/ADC score 3 remains category 3 when DCE is negative and upgrades to category 4 when DCE is positive. In the transition zone, category 3 results from T2W score 2 with DWI/ADC at least 4, or T2W score 3 with DWI/ADC no greater than 4. | Biopsy may or may not be appropriate. PI-RADS v2.1 supplies no PSA-density cutoff or fixed follow-up interval; the decision must use factors outside mpMRI, including laboratory and clinical history, local expertise, and standards of care. | The presence of clinically significant prostate cancer is equivocal. Category 3 is deliberately an uncertainty state and does not itself justify a deterministic biopsy or surveillance instruction. | ACR/ESUR/AdMeTech PI-RADS v2.1 assessment-category and management-scope text p 10; peripheral- and transition-zone matrices p 11; DCE definition/caveats pp 22-23. | ✓ |
| 4 | High | High likelihood. In the peripheral zone, DWI/ADC score 4 maps to category 4, as does DWI/ADC score 3 with positive focal DCE. In the transition zone, T2W score 4 maps here, and T2W score 3 upgrades here only when DWI/ADC is 5. Score-4 morphology or diffusion restriction is under 15 mm unless definite extraprostatic extension is present. | Biopsy should be considered, but PI-RADS v2.1 does not make it mandatory and does not prescribe the biopsy strategy. Final management must incorporate laboratory and clinical history, local expertise, and standards of care. | Clinically significant prostate cancer is likely to be present. The category is a qualitative imaging likelihood and should remain separate from patient-level pretest probability and management. | ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-23; management-scope paragraph p 10 and zone matrices p 11. | ✓ |
| 5 | Very high | Very high likelihood. In the peripheral zone, DWI/ADC score 5 determines category 5; in the transition zone, T2W score 5 determines category 5. The defining score-5 lesion is at least 15 mm in greatest dimension with score-4 features, or shows definite extraprostatic extension or invasive behavior. | Biopsy should be considered, but PI-RADS v2.1 does not make it mandatory and does not prescribe downstream treatment. Final management must incorporate laboratory and clinical history, local expertise, and standards of care. | Clinically significant prostate cancer is highly likely to be present. This is the highest qualitative PI-RADS likelihood category, not a histopathologic diagnosis or a fixed percentage. | ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; assessment-category meaning and management-scope paragraph p 10. | ✓ |

### Per-category citations
- **1**: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033 · ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; assessment-category meaning and management-scope paragraph p 10.
- **2**: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033 · ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; transition-zone matrix p 11 and management-scope paragraph p 10.
- **3**: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033 · ACR/ESUR/AdMeTech PI-RADS v2.1 assessment-category and management-scope text p 10; peripheral- and transition-zone matrices p 11; DCE definition/caveats pp 22-23.
- **4**: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033 · ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-23; management-scope paragraph p 10 and zone matrices p 11.
- **5**: Turkbey B, Rosenkrantz AB, Haider MA, et al.. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2 (2019) — https://doi.org/10.1016/j.eururo.2019.02.033 · ACR/ESUR/AdMeTech PI-RADS v2.1 pp 10-11, 18, and 20-21; assessment-category meaning and management-scope paragraph p 10.

## Cross-references
- _shared boundary_ → [BI-RADS — Breast Imaging Reporting and Data System, 5th edition](https://radcommons.laudos.ai/systems/bi-rads-2013.md) — Shares the Reporting and Data System framework that BI-RADS established.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2019-03-01 | revised | PI-RADS v2.1 published, updating v2 (2015). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/pi-rads-v2-1 · API JSON: https://radcommons.laudos.ai/api/v1/systems/pi-rads-v2-1 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lund-Mackay — Lund-Mackay CT staging of chronic rhinosinusitis

> Scores paranasal sinus opacification on CT to stage chronic rhinosinusitis, summing paired sinus groups and the ostiomeatal complex to a maximum of 24.

**Status:** current · **Organ:** Sinonasal · **Issuing body:** Rhinology consensus / AAO-HNS Task Force · **Version:** 1993 · **Year:** 1993

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT
- Primary source: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return every right/left component, both side subtotals and the exact 0-24 total. Keep anatomic variants separate and do not invent severity cutoffs.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Per-sinus score 0, no abnormality or opacification | For one maxillary, anterior ethmoid, posterior ethmoid, sphenoid or frontal sinus on one side, assign 0 when CT shows no abnormality or opacification. An aplastic frontal sinus also contributes 0 and is recorded separately as an anatomic variant. | Use this value only as one component of right/left anatomic staging and the 0-24 total. The system defines no treatment action for a component score of 0; correlate the CT with symptoms, endoscopy and the clinical diagnosis. | This is an opacification component, not an independent outcome-risk stratum; the system assigns no per-component complication probability. | Lund and Mackay 1993, p.183, radiological staging paragraph: each sinus group 0=no abnormality, 1=partial opacification, 2=total opacification; p.183-184 and Table 1 list absent frontal sinus as a separately recorded variant. Lund and Kennedy 1997, radiologic grading discussion, addresses the absent-frontal-sinus case. | ✓ |
| 1 | Per-sinus score 1, partial opacification | For one maxillary, anterior ethmoid, posterior ethmoid, sphenoid or frontal sinus on one side, assign 1 when CT shows partial opacification. All degrees of partial opacification remain in this single category. | Use this value only as one component of right/left anatomic staging and the 0-24 total. The system defines no treatment action for partial opacification alone; correlate the CT with symptoms, endoscopy and the clinical diagnosis. | This is an opacification component, not an independent outcome-risk stratum; the system assigns no per-component complication probability. | Lund and Mackay 1993, p.183, radiological staging and simplification paragraphs: score 1 means partial opacification and intentionally combines every degree of partial opacification in one category. | ✓ |
| 2 | Per-sinus score 2, total opacification | For one maxillary, anterior ethmoid, posterior ethmoid, sphenoid or frontal sinus on one side, assign 2 when CT shows total opacification of that sinus group. | Use this value only as one component of right/left anatomic staging and the 0-24 total. The system defines no treatment action for total opacification alone; correlate the CT with symptoms, endoscopy and the clinical diagnosis. | This is an opacification component, not an independent outcome-risk stratum; the system assigns no per-component complication probability. | Lund and Mackay 1993, p.183, radiological staging paragraph and p.184 Table 1: score 2 means total opacification for each sinus group. | ✓ |
| OMC | Ostiomeatal complex, 0 if not obstructed or 2 if obstructed | Score the ostiomeatal complex separately on each side: 0 when it is not obstructed and 2 when it is obstructed. There is no 1-point OMC state. | Add the OMC value to the five ipsilateral sinus-group values. The system defines no OMC-specific treatment action; describe the obstruction and integrate it with the remaining CT, endoscopic and clinical findings. | OMC 0 or 2 is a staging component rather than a standalone risk category, and the original system provides no OMC-specific event probability. | Lund and Mackay 1993, p.183, radiological staging paragraph and p.184 Table 1: OMC is 0 if unobstructed or 2 if obstructed. | ✓ |
| TOTAL | Exact bilateral Lund-Mackay total, 0-24 | Sum the maxillary, anterior ethmoid, posterior ethmoid, sphenoid, frontal and OMC values on each side for a subtotal of 0-12; add right and left subtotals for the exact bilateral Lund-Mackay total of 0-24. | Report the exact right subtotal, left subtotal, bilateral total and component scores. The original system supplies no mild/moderate/severe cutoffs and no numeric threshold that by itself selects medical or surgical treatment. | A larger total denotes greater CT opacification burden, but the 0-24 scale is not divided into calibrated individual risk strata and does not supply a per-score prognosis. | Lund and Mackay 1993, p.183: total range 0-24 and 0-12 per side; p.184 Table 1 lists the five sinus groups plus OMC. The original article provides no categorical total-score bands. | ✓ |

### Per-category citations
- **0**: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf · Lund and Mackay 1993, p.183, radiological staging paragraph: each sinus group 0=no abnormality, 1=partial opacification, 2=total opacification; p.183-184 and Table 1 list absent frontal sinus as a separately recorded variant. Lund and Kennedy 1997, radiologic grading discussion, addresses the absent-frontal-sinus case.
- **1**: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf · Lund and Mackay 1993, p.183, radiological staging and simplification paragraphs: score 1 means partial opacification and intentionally combines every degree of partial opacification in one category.
- **2**: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf · Lund and Mackay 1993, p.183, radiological staging paragraph and p.184 Table 1: score 2 means total opacification for each sinus group.
- **OMC**: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf · Lund and Mackay 1993, p.183, radiological staging paragraph and p.184 Table 1: OMC is 0 if unobstructed or 2 if obstructed.
- **TOTAL**: Lund VJ, Mackay IS. Staging in rhinosinusitis (1993) — https://www.rhinologyjournal.com/Rhinology_issues/manuscript_1490.pdf · Lund and Mackay 1993, p.183: total range 0-24 and 0-12 per side; p.184 Table 1 lists the five sinus groups plus OMC. The original article provides no categorical total-score bands.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lund-mackay · API JSON: https://radcommons.laudos.ai/api/v1/systems/lund-mackay · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Keros — Keros classification of olfactory fossa depth

> Side-specific CT classification of olfactory-fossa depth from the vertical height of the lateral lamella of the cribriform plate: type I up to 3 mm, type II over 3 through 7 mm and type III over 7 mm. Return the continuous measurement and all other skull-base hazards; Keros is one anatomic descriptor, not a complete surgical-risk score or a treatment rule.

**Status:** current · **Organ:** Skull base · **Issuing body:** Keros / sinonasal and skull-base imaging literature · **Version:** 1962 depth framework; preoperative CT limitations reviewed through 2020 · **Year:** 1962

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Keros P; reproduction by Souza SA, Souza MMA, et al.. Olfactory fossa depth classification (Keros), reproduced in a CT analysis of 1200 patients (1962) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6319094/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Return one measurement and type per side, plus asymmetry and the remaining skull-base hazards. Keros describes depth only: type III is the traditional deep-fossa warning, but no type is intrinsically safe and no type alone determines surgery.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, olfactory fossa depth up to 3 mm | Keros type I: side-specific olfactory-fossa depth up to 3 mm, measured on coronal bone-window CT as the vertical difference between the cribriform plate and ethmoid roof represented by the lateral-lamella height. Return the continuous value, side and measurement location. | For preoperative planning, report the side-specific type and depth together with asymmetry, low skull-base side, lateral-lamella length and angle, dehiscence and the remaining CLOSE landmarks. Type I does not waive careful review or select a surgical technique. | Traditionally the shallowest group, but not a safe-skull-base label. Type-I patients can have a long or acutely angled lateral lamella, a low or reverse-sloping roof, asymmetry or dehiscence; Keros alone supplies no individual injury probability. | Souza et al., PMC6319094, Keros type I depth definition and measurement method; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, Figures 8-9 and CLOSE checklist; Hamour et al. 2020, DOI 10.1055/s-0040-1716690, type-I safety limitation. | ✓ |
| II | Type II, depth over 3 through 7 mm | Keros type II: side-specific olfactory-fossa depth greater than 3 mm and up to 7 mm, measured as the vertical cribriform-plate-to-ethmoid-roof difference on a true or high-quality coronal CT reformation. Preserve millimeters rather than only the ordinal type. | Communicate the measured right and left anatomy and all coexisting skull-base hazards to the operating team. The intermediate depth is one planning input and does not by itself require navigation, alter the operative corridor or mandate or prohibit surgery. | Intermediate depth exposes a longer lateral-lamella component than type I in the classic model, but complication risk also depends on side asymmetry, roof height and slope, lamellar angle and length, artery course, dehiscence and procedure. No calibrated risk percentage follows from type II. | Souza et al., PMC6319094, type II 4-7 mm description and bilateral measurements; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, coronal measurement and operative-hazard checklist; Hamour et al. 2020, PMC8824605, multidimensional limits. | ✓ |
| III | Type III, depth over 7 mm (classically 8-16 mm) | Keros type III: side-specific olfactory-fossa depth greater than 7 mm, classically reported as 8-16 mm, with a deep fossa and long vertical lateral-lamella component. Report the exact depth and side and inspect for anterior-posterior variation. | Explicitly highlight the deep side and associated skull-base anatomy for preoperative planning, while separately reporting dehiscence, asymmetry and CLOSE landmarks. The type increases anatomic caution but does not alone cancel surgery, choose instrumentation or prescribe an approach. | The classic deep-fossa warning is associated with greater vulnerability to lateral-lamella penetration and cerebrospinal-fluid leak during endoscopic surgery. It is an anatomic association rather than a personal complication probability, and other hazards can dominate in any Keros type. | Souza et al., PMC6319094, type III 8-16 mm and dangerous-ethmoid discussion; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, Keros and asymmetry figures; Hamour et al. 2020, DOI 10.1055/s-0040-1716690, warning against single-metric risk assessment. | ✓ |

### Per-category citations
- **I**: Keros P; reproduction by Souza SA, Souza MMA, et al.. Olfactory fossa depth classification (Keros), reproduced in a CT analysis of 1200 patients (1962) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6319094/ · Souza et al., PMC6319094, Keros type I depth definition and measurement method; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, Figures 8-9 and CLOSE checklist; Hamour et al. 2020, DOI 10.1055/s-0040-1716690, type-I safety limitation.
- **II**: Keros P; reproduction by Souza SA, Souza MMA, et al.. Olfactory fossa depth classification (Keros), reproduced in a CT analysis of 1200 patients (1962) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6319094/ · Souza et al., PMC6319094, type II 4-7 mm description and bilateral measurements; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, coronal measurement and operative-hazard checklist; Hamour et al. 2020, PMC8824605, multidimensional limits.
- **III**: Keros P; reproduction by Souza SA, Souza MMA, et al.. Olfactory fossa depth classification (Keros), reproduced in a CT analysis of 1200 patients (1962) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6319094/ · Souza et al., PMC6319094, type III 8-16 mm and dangerous-ethmoid discussion; O'Brien et al. 2016, DOI 10.1148/radiol.2016152230, Keros and asymmetry figures; Hamour et al. 2020, DOI 10.1055/s-0040-1716690, warning against single-metric risk assessment.

## Cross-references
- _shared boundary_ → [Lund-Mackay — Lund-Mackay CT staging of chronic rhinosinusitis](https://radcommons.laudos.ai/systems/lund-mackay.md) — Both can be reported on sinus CT, but Lund-Mackay scores inflammatory opacification while Keros measures side-specific olfactory-fossa depth. Neither value can be derived from the other.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2020-09-10 | revised | A multidimensional skull-base analysis showed that Keros type alone can mislabel hazardous type-I anatomy as safe; length, angle, slope, artery course and anterior-posterior variation remain separate observations. | confirmed |
| 2016-10-01 | revised | The RSNA CLOSE review embedded cribriform depth within a broader preoperative sinus-CT checklist and emphasized side asymmetry and adjacent surgical landmarks; it did not alter the three thresholds. | confirmed |
| 1962-01-01 | published | Keros described three olfactory-fossa depth groups based on the vertical height of the lateral lamella; the original ranges are retained as an anatomic classification. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/keros · API JSON: https://radcommons.laudos.ai/api/v1/systems/keros · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# AO Spine TL — AO Spine thoracolumbar injury classification and TL AOSIS

> Per-injury thoracolumbar-trauma framework that reports the exact A0-A4, B1-B3 or C morphology, clinical neurologic status N0-N4/NX, continued cord compression when present, and M1/M2 modifiers. TL AOSIS sums morphology, neurology and M1; thresholds of 3 or less, 4-5 and 6 or more are guidance bands, not a letter-only treatment order or calibrated prognosis.

**Status:** current · **Organ:** Spine · **Issuing body:** AO Spine · **Version:** 2013 classification; 2016 TL AOSIS and treatment-guidance algorithm; official pocket-card terminology current · **Year:** 2013

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT, MRI, Clinical
- Primary source: Vaccaro AR, Oner C, Kepler CK, et al.. AOSpine thoracolumbar spine injury classification system (2013) — https://doi.org/10.1097/BRS.0b013e3182a8a381
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify exact morphology first, add the clinical neurologic code and modifiers, show TL AOSIS arithmetic, and preserve the difference between a consensus guidance band and an individual treatment decision.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Type A, compression | Type A is a compression injury without established tension-band failure or translation. Resolve the exact subtype: A0 minor nonstructural injury; A1 wedge/impaction without posterior-wall involvement; A2 split/pincer involving both endplates without the posterior wall; A3 incomplete burst involving the posterior wall and one endplate; or A4 complete burst involving the posterior wall and both endplates. | Do not manage from the parent A label. Calculate TL AOSIS from the exact morphology (A0=0, A1=1, A2=2, A3=3, A4=5), the clinical N code and M1. Totals <=3 support an initial nonoperative trial, 4-5 allow either pathway, and >=6 support surgery; apply the band as consensus guidance with patient and injury context. | A0-A4 is an ordered morphology hierarchy, but neither the A letter nor TL AOSIS is a calibrated probability of neurologic decline, mortality, kyphosis, pain or treatment failure. Posterior-wall involvement distinguishes burst morphology; canal narrowing cannot substitute for the clinical neurologic examination. | AO Spine Surgery Reference flow chart and sections A0-A4; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Tables 3-4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, abstract treatment bands. | ✓ |
| B | Type B, tension band | Type B is tension-band failure without translation. Resolve B1, a pure monosegmental transosseous posterior disruption (Chance); B2, posterior osseoligamentous or soft-tissue/bony tension-band disruption; or B3, anterior tension-band failure in hyperextension, often in an ankylotic spine. Record the injured motion segment and any associated A subtype. | Use the subtype before applying TL AOSIS: B1 contributes 5 points and is in the 4-5 either-pathway band when N0 and M1 are absent, whereas B2=6 and B3=7 already enter the surgical-guidance band. Add N and M1, preserve M2 context, and do not treat the parent B label as an automatic operation. | B injuries represent tension-band disruption and greater perceived injury severity, but the score encodes international surgeon consensus rather than an individual adverse-event probability. B1, B2 and B3 are not equivalent, and M2 factors such as ankylosing disease can materially change risk and care despite adding zero points. | AO Spine Surgery Reference sections B1-B3, associated-A nomenclature and modifiers; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Tables 3-4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, treatment algorithm. | ✓ |
| C | Type C, translation | Type C is displacement, dislocation or translation in any plane with separation of the anterior and posterior components of a motion segment. It takes precedence over A or B as the principal morphology, while the involved level and associated vertebral-body A subtype or tension-band injury must still be recorded. | Type C contributes 8 morphology points, so it exceeds the TL AOSIS surgical-intervention threshold before neurologic or M1 points are added. Treat this as a prompt for urgent spine-specialist assessment and stabilization planning, not an autonomous order that overrides resuscitation, contraindications, goals of care, polytrauma priorities or M2 context. | C is the highest morphology tier and is translationally unstable, but it does not quantify a patient's probability of paralysis, mortality or surgical outcome. Report displacement, canal compromise, clinical neurology, continued cord compression and associated injuries separately instead of using C as a complete prognosis. | AO Spine Surgery Reference sections Type C and nomenclature; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Table 3 (C=8) and Table 4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, >5 surgical-guidance threshold. | ✓ |

### Per-category citations
- **A**: Vaccaro AR, Schroeder GD, Kepler CK, et al.. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system (2016) — https://pubmed.ncbi.nlm.nih.gov/25953527/ · AO Spine Surgery Reference flow chart and sections A0-A4; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Tables 3-4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, abstract treatment bands.
- **B**: Vaccaro AR, Schroeder GD, Kepler CK, et al.. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system (2016) — https://pubmed.ncbi.nlm.nih.gov/25953527/ · AO Spine Surgery Reference sections B1-B3, associated-A nomenclature and modifiers; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Tables 3-4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, treatment algorithm.
- **C**: Vaccaro AR, Schroeder GD, Kepler CK, et al.. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system (2016) — https://pubmed.ncbi.nlm.nih.gov/25953527/ · AO Spine Surgery Reference sections Type C and nomenclature; Kepler et al. Global Spine J 2016, DOI 10.1055/s-0035-1563610, Table 3 (C=8) and Table 4; Vaccaro et al. Eur Spine J 2016, DOI 10.1007/s00586-015-3982-2, >5 surgical-guidance threshold.

## Cross-references
- _shared boundary_ → [TLICS — Thoracolumbar Injury Classification and Severity score](https://radcommons.laudos.ai/systems/tlics.md) — AO Spine TL and TLICS describe overlapping thoracolumbar trauma but use different morphology taxonomies, ligament treatment and thresholds. Preserve raw CT, MRI and clinical-examination facts and calculate each framework independently.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2019-01-01 | revised | The CNS evidence-based guideline supported classification for communication but found insufficient evidence for a universal severity score to determine all treatment or predict outcomes. This is a use boundary, not a new AO category set. | confirmed |
| 2016-04-01 | revised | The AO Spine surgical-algorithm study defined the initial guidance bands: 3 or less for a nonoperative trial, 4-5 for either pathway, and more than 5 for surgical intervention. | confirmed |
| 2015-09-29 | revised | Kepler and colleagues published the companion TL AOSIS point table for A0-A4, B1-B3, C, N0-N4/NX and M1/M2. This added a score without changing the morphology labels. | confirmed |
| 2013-11-01 | published | AOSpine thoracolumbar classification published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aospine-tl · API JSON: https://radcommons.laudos.ai/api/v1/systems/aospine-tl · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Anderson-D'Alonzo — Anderson and D'Alonzo classification of odontoid fractures

> Classifies fractures of the odontoid process (dens) of C2 by anatomic location into three types.

**Status:** current · **Organ:** Spine · **Issuing body:** Orthopedic / spine consensus · **Version:** 1974 · **Year:** 1974

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, XR
- Primary source: Stulík J, Vyskocil T, Sebesta P, Kryl J (StatPearls); after Anderson LD, D'Alonzo RT 1974. Anderson and D'Alonzo classification of odontoid (dens) fractures (2024) — https://www.ncbi.nlm.nih.gov/books/NBK441956/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, apex (tip) of the dens | Type I: fracture involving the apex (tip) of the odontoid process, above the transverse ligament, generally representing an avulsion at the alar ligament insertion. | Generally stable and treated conservatively; if instability is suspected (e.g., alar ligament avulsion), dynamic radiographs are recommended to evaluate. | Usually stable; least common type. Instability is a concern only if associated ligamentous disruption is present. | StatPearls NBK441956 (Odontoid Fractures): 'Type I odontoid fractures involve the apex of the dens and are generally stable. However, if instability is suspected... dynamic radiographic imaging is recommended.' | ✓ |
| II | Type II, base/neck of the dens | Type II: fracture through the neck (base) of the odontoid process, at the junction with the C2 body. Subtypes by fracture-line pattern (anterior oblique, posterior oblique, horizontal); the type IIA variant is an unstable comminuted fracture at the dens base. | Most common subtype and generally considered unstable; management is individualized (immobilization vs surgical fixation) given the well-known risk of nonunion, particularly in the comminuted IIA variant. | Highest nonunion risk of the three types because the fracture crosses the watershed neck of the dens; generally unstable. | StatPearls NBK441956: 'Type II... involve the neck of the odontoid process... the most common subtype and are generally considered unstable. The type IIA variant specifically features unstable comminuted fractures at the base of the dens.' | ✓ |
| III | Type III, fracture extending into the C2 body | Type III: fracture extending below the base of the dens into the cancellous body of C2 (and may involve the C1-C2 facet joints). | Non-surgical treatment with external immobilization is the preferable option for most patients, owing to the broad cancellous fracture surface and better union potential. | Better healing potential than type II because of the large cancellous bone contact area; generally treated nonoperatively. | StatPearls NBK441956: 'Type III fractures extend into the body of C2. Non-surgical treatment with external immobilization remains the preferable option for most patients with this type of fracture.' | ✓ |

### Per-category citations
- **I**: Stulík J, Vyskocil T, Sebesta P, Kryl J (StatPearls); after Anderson LD, D'Alonzo RT 1974. Anderson and D'Alonzo classification of odontoid (dens) fractures (2024) — https://www.ncbi.nlm.nih.gov/books/NBK441956/ · StatPearls NBK441956 (Odontoid Fractures): 'Type I odontoid fractures involve the apex of the dens and are generally stable. However, if instability is suspected... dynamic radiographic imaging is recommended.'
- **II**: Stulík J, Vyskocil T, Sebesta P, Kryl J (StatPearls); after Anderson LD, D'Alonzo RT 1974. Anderson and D'Alonzo classification of odontoid (dens) fractures (2024) — https://www.ncbi.nlm.nih.gov/books/NBK441956/ · StatPearls NBK441956: 'Type II... involve the neck of the odontoid process... the most common subtype and are generally considered unstable. The type IIA variant specifically features unstable comminuted fractures at the base of the dens.'
- **III**: Stulík J, Vyskocil T, Sebesta P, Kryl J (StatPearls); after Anderson LD, D'Alonzo RT 1974. Anderson and D'Alonzo classification of odontoid (dens) fractures (2024) — https://www.ncbi.nlm.nih.gov/books/NBK441956/ · StatPearls NBK441956: 'Type III fractures extend into the body of C2. Non-surgical treatment with external immobilization remains the preferable option for most patients with this type of fracture.'


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/anderson-dalonzo · API JSON: https://radcommons.laudos.ai/api/v1/systems/anderson-dalonzo · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Bilsky ESCC — Epidural spinal cord compression (ESCC / Bilsky) scale

> Per-level six-category MRI morphology for neoplastic epidural disease, assigned on axial T2 at the site of greatest cord compromise. ESCC supplies the neurologic imaging axis of NOMS; it neither measures mechanical instability nor independently chooses surgery or radiation.

**Status:** current · **Organ:** Spine · **Issuing body:** Spine Oncology Study Group · **Version:** 2010 scale; current NOMS, NICE 2023 and ASTRO 2024 context · **Year:** 2010

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Assign ESCC per involved cord level on axial T2, preserve uncertainty and emergency red flags, and integrate rather than conflate the neurologic, oncologic, mechanical and systemic NOMS axes.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, bone-only disease | At the named spinal cord level on axial T2 MRI, neoplastic involvement is confined to bone with no tumor extending into the epidural space or spinal canal. Confirm the apparent absence of epidural disease across multiplanar images and distinguish fracture fragments or non-tumor material. | Report grade 0 per involved level and separately assess pain, fracture, alignment and SINS/mechanical stability. Within NOMS, low-grade epidural morphology may support radiation-first oncologic care when treatment is needed and stability/systemic factors permit, but grade 0 alone neither orders treatment nor excludes surgical referral for instability. | There is no neoplastic epidural cord compromise at that level by the scale, but bone-only disease can still fracture, collapse, deform or cause mechanical pain. ESCC 0 is not a low overall patient-risk label and does not predict neurologic trajectory, survival or treatment response. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, six-point definition of grade 0; Laufer et al. 2013, PMC4063402, Neurologic Assessment and Mechanical Assessment for low-grade ESCC versus SINS/NOMS context. | ✓ |
| 1a | Grade 1a, epidural impingement, no thecal sac deformation | Epidural neoplastic impingement is present on axial T2 MRI, but the thecal sac contour is not deformed. Identify the level, direction and craniocaudal extent of epidural tumor rather than recording only the category. | Treat 1a as low-grade epidural disease within the neurologic NOMS axis and integrate tumor radiosensitivity, prior radiation, SINS stability, neurologic status and systemic fitness. It commonly remains in a radiation-first pathway when otherwise appropriate, but this tendency is conditional and not a grade-only command. | The epidural compartment is involved, although the sac is not yet deformed. Progression risk depends on tumor biology, treatment and time; 1a does not provide a calibrated probability of later compression and must not obscure instability or rapidly evolving neurologic symptoms. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1a definition; Laufer et al. 2013, PMC4063402, ESCC Figure 1 and NOMS low-grade treatment context. | ✓ |
| 1b | Grade 1b, thecal sac deformation, no cord abutment | Epidural tumor deforms the thecal sac on axial T2 MRI without abutting the spinal cord. Demonstrable sac deformation distinguishes 1b from 1a; demonstrable cord contact would move the morphology to 1c. | Report 1b per level with the epidural direction/length and keep cord signal, fracture and stability separate. NOMS generally treats 0-1b as low-grade ESCC for oncologic planning, but management still requires histology/radiosensitivity, prior treatment, examination, SINS and systemic feasibility. | Thecal-sac deformation represents greater epidural compromise than 1a but there is no cord contact or compression by definition. The category remains an ordinal morphology, not an individualized paralysis, recovery or survival estimate. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1b definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment for low-grade ESCC and conditional radiation context. | ✓ |
| 1c | Grade 1c, thecal sac deformation with cord abutment, no compression | Epidural tumor deforms the thecal sac and directly abuts the spinal cord, but the cord itself is not compressed. If contact versus deformation cannot be resolved, preserve 1b-versus-1c uncertainty; if the cord is deformed/compressed, evaluate grade 2 or 3. | Escalate 1c for multidisciplinary NOMS review rather than silently grouping it with either 0-1b or 2-3. The original NOMS publication describes uncertainty about the role and durability of radiosurgery at this boundary; symptoms, radiosensitivity, prior radiation, stability and systemic status determine the actual plan. | Cord contact without compression is an important boundary state, but it is not a validated probability of neurologic deterioration. Rapid clinical decline or myelopathy overrides the stored category and requires emergency assessment even when the morphology remains 1c. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1c definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment noting unresolved grade 1c radiosurgery role. | ✓ |
| 2 | Grade 2, cord compression with CSF visible around the cord | The spinal cord is compressed/deformed by epidural neoplastic disease, while cerebrospinal fluid remains visibly interposed around at least part of the cord on the maximal axial T2 image. If residual CSF cannot be judged, retain grade 2-versus-3 uncertainty. | Grade 2 is high-grade ESCC and warrants urgent multidisciplinary assessment. NOMS commonly considers decompression before radiation for radioresistant tumors, while highly radiosensitive histologies and other patient factors may support a different pathway; current ASTRO guidance conditionally favors surgery plus postoperative radiation over radiation alone in appropriate cord/cauda-equina compression patients. | True cord compression is present. Neurologic risk depends on examination, cord signal, speed of onset, level, tumor and treatment timing; the presence of residual CSF does not make symptomatic compression nonurgent or supply an individual probability of paralysis. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 2 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC NOMS pathway; NICE NG234 recommendations 1.5.2-1.5.5 for urgent MRI; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, cord/cauda-equina compression recommendation context. | ✓ |
| 3 | Grade 3, cord compression with no CSF visible | The spinal cord is compressed by epidural neoplastic disease and no surrounding cerebrospinal-fluid signal remains visible at the site of maximal compression on axial T2 MRI. Verify technical quality and exact level before assigning the category. | Grade 3 is high-grade ESCC and requires urgent MSCC-pathway escalation, with immediate attention to neurologic deficits and ambulation. Surgical, radiation and corticosteroid decisions remain multidisciplinary and patient-specific; tumor radiosensitivity, prior radiation, SINS stability, systemic fitness and goals of care must accompany the grade. | This is the greatest cord-compromise morphology in the scale, but it is not synonymous with irreversible paralysis or futility. Outcome depends on baseline and evolving neurology, duration, cord injury, tumor and timely treatment, so no universal recovery or mortality percentage should be attached. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 3 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC/NOMS; NICE NG234 MSCC emergency pathway; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, multimodality treatment context. | ✓ |

### Per-category citations
- **0**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, six-point definition of grade 0; Laufer et al. 2013, PMC4063402, Neurologic Assessment and Mechanical Assessment for low-grade ESCC versus SINS/NOMS context.
- **1a**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1a definition; Laufer et al. 2013, PMC4063402, ESCC Figure 1 and NOMS low-grade treatment context.
- **1b**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1b definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment for low-grade ESCC and conditional radiation context.
- **1c**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1c definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment noting unresolved grade 1c radiosurgery role.
- **2**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 2 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC NOMS pathway; NICE NG234 recommendations 1.5.2-1.5.5 for urgent MRI; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, cord/cauda-equina compression recommendation context.
- **3**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 3 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC/NOMS; NICE NG234 MSCC emergency pathway; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, multimodality treatment context.

## Cross-references
- _shared boundary_ → [SINS — Spinal Instability Neoplastic Score](https://radcommons.laudos.ai/systems/sins.md) — Components of the NOMS framework for metastatic spine disease: ESCC grades neurologic/cord compromise, SINS grades mechanical instability.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2010-09-01 | published | Epidural spinal cord compression scale reliability analysis published in J Neurosurg Spine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/bilsky-escc · API JSON: https://radcommons.laudos.ai/api/v1/systems/bilsky-escc · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Denis — Denis three-column classification of spinal injury

> Classifies thoracolumbar fractures by spinal columns involved.

**Status:** current · **Organ:** Spine · **Issuing body:** Spine consensus · **Version:** 1983 · **Year:** 1983

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Denis F. The three-column spine and its significance in thoracolumbar injuries (Denis) (1983) — https://doi.org/10.1097/00007632-198311000-00003
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| compression | Compression fracture | Failure of the anterior column (anterior vertebral body) under flexion/axial load with the middle column intact, so the posterior vertebral wall and spinal canal are preserved. | Generally stable: conservative management (bracing; vertebroplasty/kyphoplasty in selected cases). Posterior instrumentation/fusion reserved for severe injuries (e.g. >50% body-height loss or significant kyphosis). | Mechanically stable with low neurologic risk because the middle column and canal are spared. | NBK544310: compression = anterior column only, middle intact; stable, low neurologic risk; conservative bracing, surgery for severe height loss/kyphosis. | ✓ |
| burst | Burst fracture | Compressive failure of both the anterior and middle columns; the middle column (posterior vertebral wall) is breached, often with retropulsion of bone into the canal; the posterior column may or may not be involved. | Considered unstable: bracing for neurologically intact, mechanically stable cases; decompression with instrumented fusion when there is neurologic deficit, significant canal compromise, deformity, or posterior ligamentous disruption. | Unstable with moderate-to-high neurologic risk owing to middle-column failure and possible canal retropulsion. | NBK544310: burst = anterior + middle column failure; unstable, moderate-high neurologic risk; bracing vs decompression/instrumented fusion per deficit/canal/deformity. | ✓ |
| seat-belt | Seat-belt (Chance) injury | Flexion-distraction (seat-belt / Chance-type) injury: distraction failure that typically disrupts the posterior and middle columns (and may extend through all three) without anterior translation. | Unstable in distraction: bracing for minimally displaced bony (Chance) injuries; posterior instrumentation +/- fusion for ligamentous injury or kyphotic deformity (e.g. >20 degrees). | Unstable through distraction with moderate neurologic risk; associated intra-abdominal injuries are common with the seat-belt mechanism. | NBK544310: flexion-distraction = distraction across columns, no translation; unstable, moderate neurologic risk; bracing vs posterior instrumentation per displacement/kyphosis. | ✓ |
| fracture-dislocation | Fracture-dislocation | Failure of all three columns with associated translation/displacement (and/or rotation); mechanisms include shear, rotation, flexion, and tension. | Most unstable pattern: essentially all require operative open reduction with instrumented fusion (often with decompression). | Highly unstable with the highest neurologic injury risk of the Denis types due to three-column failure with translation. | NBK544310: fracture-dislocation = all three columns + translation; highly unstable, high neurologic risk; all require open reduction with instrumented fusion. | ✓ |

### Per-category citations
- **compression**: Denis F. The three-column spine and its significance in thoracolumbar injuries (Denis) (1983) — https://doi.org/10.1097/00007632-198311000-00003 · NBK544310: compression = anterior column only, middle intact; stable, low neurologic risk; conservative bracing, surgery for severe height loss/kyphosis.
- **burst**: Denis F. The three-column spine and its significance in thoracolumbar injuries (Denis) (1983) — https://doi.org/10.1097/00007632-198311000-00003 · NBK544310: burst = anterior + middle column failure; unstable, moderate-high neurologic risk; bracing vs decompression/instrumented fusion per deficit/canal/deformity.
- **seat-belt**: Denis F. The three-column spine and its significance in thoracolumbar injuries (Denis) (1983) — https://doi.org/10.1097/00007632-198311000-00003 · NBK544310: flexion-distraction = distraction across columns, no translation; unstable, moderate neurologic risk; bracing vs posterior instrumentation per displacement/kyphosis.
- **fracture-dislocation**: Denis F. The three-column spine and its significance in thoracolumbar injuries (Denis) (1983) — https://doi.org/10.1097/00007632-198311000-00003 · NBK544310: fracture-dislocation = all three columns + translation; highly unstable, high neurologic risk; all require open reduction with instrumented fusion.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/denis · API JSON: https://radcommons.laudos.ai/api/v1/systems/denis · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Genant — Genant visual semiquantitative vertebral fracture grading

> Per-vertebra visual fracture assessment from T4 through L4 using morphology plus anterior, middle or posterior height loss and projected-area loss; morphometry confirms severity but cannot diagnose fracture alone.

**Status:** current · **Organ:** Spine · **Issuing body:** Genant et al. / International Society for Clinical Densitometry · **Version:** 1993 original; 2023 ISCD VFA technique of choice · **Year:** 1993

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, DXA, CT
- Primary source: Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique (1993) — https://doi.org/10.1002/jbmr.5650080915
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Diagnose fracture visually before grading severity. Preserve level, morphology, measurements, borderline or subthreshold states, differential diagnosis and modality; never infer osteoporosis treatment or acuity from the grade alone.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, normal | Grade 0: the identified vertebra has expected regional shape and no visual endplate, cortical or configuration change consistent with fracture. Height loss below 20% supports Grade 0 only when morphology is normal; a definite subthreshold endplate fracture or a questionable deformity must not be hidden in this category. | List the vertebral level and technical evaluability. Grade 0 at one level requires no fracture-specific action from this scale, but it does not exclude fracture at another level, low bone density or another cause of symptoms and cannot determine osteoporosis care. | Grade 0 means no visual fracture at the assessed level, not zero future fracture risk. Risk still depends on age, bone density, prior fractures, medications and clinical factors, which the Genant code does not quantify. | Grigoryan et al. 2003, PMC3591834, Genant visual semiquantitative assessment and Figs. 1-3: normal Grade 0 requires visual assessment against adjacent and expected regional morphology; the text warns that normal wedging, biconcavity and degenerative remodeling can mimic mild fracture. | ✓ |
| 0.5 | Grade 0.5, borderline or questionable deformity | Optional Grade 0.5: a borderline vertebra shows some deformation but cannot be clearly assigned a definite Grade 1 fracture. Preserve the observed endplate, cortex, shape and height findings; Grade 0.5 is an uncertainty category, not a definitive mild osteoporotic fracture. | Compare prior imaging and clinical context and consider diagnostic radiography or other imaging when confirmation would change care, especially with malignancy, a lytic or sclerotic feature, an unidentifiable level or another non-benign concern. Do not initiate grade-specific treatment from 0.5 alone. | Borderline and mild deformities have the greatest reader subjectivity and may reflect normal variation or non-osteoporotic disease. The 0.5 label carries no calibrated probability that the vertebra is fractured or that another fracture will occur. | Grigoryan et al. 2003, PMC3591834, visual semiquantitative description states that Grade 0.5 is sometimes used for deformation not clearly assignable to Grade 1 and discusses subjectivity of borderline and mild deformities. ISCD 2023 lists equivocal fracture as an indication for follow-up imaging based on the clinical picture. | ✓ |
| 1 | Grade 1, mild fracture | Grade 1 mild fracture: a visually credible vertebral fracture with approximately 20-25% reduction in anterior, middle or posterior height and approximately 10-20% reduction in projected vertebral-body area. Report wedge, biconcave or crush shape separately and exclude a normal or degenerative mimic. | Clearly report the mild fracture and integrate age, symptoms, BMD, prior fractures, glucocorticoids and secondary causes under local osteoporosis guidance. The grade alone does not choose medication, vertebral augmentation, surgery or follow-up timing; equivocal Grade 1 morphology may require confirmation. | A prevalent vertebral fracture is clinically relevant and associated with later fracture and morbidity, but Grade 1 does not supply an individual risk percentage. Mild grades are the most vulnerable to projection, regional shape and reader variation. | Grigoryan et al. 2003, PMC3591834, visual SQ section: Grade 1 is 20-25% height and 10-20% projected-area reduction; the article explains morphology, nonfracture differentials, mild-grade subjectivity and future-fracture association. ISCD 2023 requires visual fracture diagnosis rather than morphometry alone. | ✓ |
| 2 | Grade 2, moderate fracture | Grade 2 moderate fracture: a visually credible fracture with approximately 26-40% reduction in anterior, middle or posterior height and approximately 21-40% reduction in projected vertebral-body area. Preserve exact level, measurements and morphology and distinguish osteoporosis from trauma, neoplasm or another deforming process. | Communicate the moderate vertebral fracture and any acuity or pathologic features and support appropriate osteoporosis or secondary-cause evaluation. Genant Grade 2 alone cannot select a drug, brace, procedure or surgical pathway; neurologic or malignant features require their own urgent assessment. | Moderate vertebral fracture indicates greater structural deformity and contributes to clinical fracture-risk assessment, but it is not a stand-alone probability model. Patient risk remains dependent on the full fracture history, BMD and clinical context. | Grigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 2 as 26-40% height and 21-40% area reduction and details visual morphology and differential diagnosis. ISCD 2023 retains the method for VFA and specifies follow-up imaging for malignant, equivocal, lytic or sclerotic concerns. | ✓ |
| 3 | Grade 3, severe fracture | Grade 3 severe fracture: a visually credible vertebral fracture with greater than 40% reduction in vertebral height and projected area. The configuration may be wedge, biconcave or crush; severe collapse still requires assessment for traumatic, neoplastic, infectious and other non-osteoporotic causes. | Report severe collapse, level, canal or neurologic implications, acuity features and any suspicious bone destruction separately and prompt appropriate specialist evaluation. The grade does not autonomously determine osteoporosis therapy, augmentation, stabilization or oncologic care. | Grade 3 is the maximum Genant severity category and represents substantial structural loss, but the classification gives no patient-specific mortality, neurologic or future-fracture probability. Etiology, acuity, multiplicity and clinical risk factors remain decisive. | Grigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 3 as greater than 40% height and projected-area reduction and separates severity from wedge, biconcave or crush shape; differential-diagnosis sections require visual exclusion of non-osteoporotic deformity. | ✓ |

### Per-category citations
- **0**: Grigoryan M, Guermazi A, Roemer FW, Delmas PD, Genant HK. Recognizing and reporting osteoporotic vertebral fractures (2003) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3591834/ · Grigoryan et al. 2003, PMC3591834, Genant visual semiquantitative assessment and Figs. 1-3: normal Grade 0 requires visual assessment against adjacent and expected regional morphology; the text warns that normal wedging, biconcavity and degenerative remodeling can mimic mild fracture.
- **0.5**: Grigoryan M, Guermazi A, Roemer FW, Delmas PD, Genant HK. Recognizing and reporting osteoporotic vertebral fractures (2003) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3591834/ · Grigoryan et al. 2003, PMC3591834, visual semiquantitative description states that Grade 0.5 is sometimes used for deformation not clearly assignable to Grade 1 and discusses subjectivity of borderline and mild deformities. ISCD 2023 lists equivocal fracture as an indication for follow-up imaging based on the clinical picture.
- **1**: Grigoryan M, Guermazi A, Roemer FW, Delmas PD, Genant HK. Recognizing and reporting osteoporotic vertebral fractures (2003) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3591834/ · Grigoryan et al. 2003, PMC3591834, visual SQ section: Grade 1 is 20-25% height and 10-20% projected-area reduction; the article explains morphology, nonfracture differentials, mild-grade subjectivity and future-fracture association. ISCD 2023 requires visual fracture diagnosis rather than morphometry alone.
- **2**: Grigoryan M, Guermazi A, Roemer FW, Delmas PD, Genant HK. Recognizing and reporting osteoporotic vertebral fractures (2003) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3591834/ · Grigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 2 as 26-40% height and 21-40% area reduction and details visual morphology and differential diagnosis. ISCD 2023 retains the method for VFA and specifies follow-up imaging for malignant, equivocal, lytic or sclerotic concerns.
- **3**: Grigoryan M, Guermazi A, Roemer FW, Delmas PD, Genant HK. Recognizing and reporting osteoporotic vertebral fractures (2003) — https://pmc.ncbi.nlm.nih.gov/articles/PMC3591834/ · Grigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 3 as greater than 40% height and projected-area reduction and separates severity from wedge, biconcave or crush shape; differential-diagnosis sections require visual exclusion of non-osteoporotic deformity.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1993-09-01 | published | Genant semiquantitative vertebral fracture grading published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/genant · API JSON: https://radcommons.laudos.ai/api/v1/systems/genant · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Lenke — Lenke 2D classification of operative adolescent idiopathic scoliosis

> Full operative-AIS designation combining curve type 1-6, lumbar modifier A/B/C and thoracic sagittal modifier minus/N/plus from standing and side-bending radiographs. It describes a two-dimensional deformity pattern and assists surgical planning but does not itself establish surgical indication, fusion levels, progression risk or the newer transverse-plane 3D modifiers.

**Status:** current · **Organ:** Spine · **Issuing body:** Lenke et al. / Scoliosis Research Society · **Version:** 2001 classic 2D AIS system; 2026 SRS-Lenke-Aubin 3D extension tracked separately · **Year:** 2001

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR
- Primary source: Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis (2001) — https://pubmed.ncbi.nlm.nih.gov/11507125/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Produce the complete classic 2D code only from a complete standing and flexibility series. Preserve the raw measurements, treat 1-6 as patterns rather than severity, and keep the 2026 3D extension explicitly separate.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Type 1, main thoracic | Main thoracic pattern: the main thoracic curve is the structural major curve; proximal thoracic and thoracolumbar/lumbar curves are nonstructural. Structurality requires the major-curve rule or a minor residual side-bending Cobb angle of at least 25 degrees, with the applicable regional sagittal threshold also considered. A complete designation still requires lumbar A/B/C and T5-T12 sagittal minus/N/plus modifiers. | Use the full type-plus-modifiers pattern to support operative deformity planning, while separately assessing shoulder/trunk balance, flexibility, rotation, maturity, symptoms and goals. Type 1 may inform consideration of a selective thoracic strategy, but it does not prescribe fusion levels or establish that surgery is indicated. | Type 1 is a morphology, not a low-risk or single-curve prognosis label. Progression and outcome depend on Cobb magnitude, growth remaining, serial change, balance and treatment; no validated per-type probability should be attached. | Slattery and Verma 2018, PMC6259994, Table 1 Curve Types, Structural Curves, Lumbar Spine Modifiers and Thoracic Sagittal Modifier; Lenke et al. 2001, PMID 11507125. | ✓ |
| 2 | Type 2, double thoracic | Double thoracic pattern: proximal thoracic and main thoracic curves are structural, the main thoracic curve is major, and the thoracolumbar/lumbar curve is nonstructural. Proximal-thoracic structurality may arise from residual bending Cobb of at least 25 degrees or T2-T5 kyphosis of at least 20 degrees. Append the lumbar and sagittal modifiers to form the full code. | The structural proximal thoracic curve is relevant to shoulder and upper-instrumentation planning, but Type 2 alone does not select the upper or lower instrumented vertebra. Integrate radiographic balance/flexibility, clinical shoulders and trunk, maturity, rotation and patient-specific operative goals. | Type 2 does not quantify progression, postoperative shoulder imbalance or revision risk. Those outcomes require patient-, measurement-, technique- and treatment-specific evidence rather than a type-number inference. | Slattery and Verma 2018, PMC6259994, Table 1 and Structural Curves section, including PT sagittal structural criterion; Lenke et al. 2001, PMID 11507125. | ✓ |
| 3 | Type 3, double major | Double major pattern: the main thoracic curve is the structural major curve, the thoracolumbar/lumbar curve is also structural, and the proximal thoracic curve is nonstructural. Distinguish Type 3 from Type 6 by major-curve identity; Type 3 is MT-major. Return the full curve type, lumbar modifier and sagittal modifier. | Both structural regions must be represented in multidisciplinary operative planning, but the label does not mandate fusion of every structural curve or define exact levels. Preserve the measured flexibility, coronal/sagittal balance, trunk shift, rotation, maturity and clinical goals that drive the actual construct. | Type 3 is not intrinsically a worse prognostic grade than Types 1-2 and supplies no natural-history or surgical-outcome percentage. Risk assessment requires magnitude, growth, balance, symptoms and the proposed treatment. | Slattery and Verma 2018, PMC6259994, Table 1 Curve Types and discussion of major versus structural curves; Lenke et al. 2001, PMID 11507125. | ✓ |
| 4 | Type 4, triple major | Triple major pattern: proximal thoracic, main thoracic and thoracolumbar/lumbar curves are all structural. The major curve may be either main thoracic or thoracolumbar/lumbar, whichever has the largest Cobb angle; it is incorrect to force the main thoracic curve to be major. Add lumbar and sagittal modifiers for the complete designation. | Treat the classification as a complete three-region deformity map for planning, not an automatic long-fusion recipe. Exact levels and strategy require curve magnitudes/flexibility, shoulder and trunk balance, sagittal profile, rotation, maturity, neurologic/clinical findings, goals and surgeon judgment. | Type 4 denotes three structural regions but is not an ordinal maximum-severity or futility state. It does not itself predict progression, complications, pulmonary effects, disability or surgical outcome. | Slattery and Verma 2018, PMC6259994, Table 1 Curve Types (Type 4 permits MT or TL/L major) and modifier sections; Lenke et al. 2001, PMID 11507125. | ✓ |
| 5 | Type 5, thoracolumbar/lumbar | Thoracolumbar/lumbar pattern: the thoracolumbar or lumbar curve is the structural major curve; proximal thoracic and main thoracic curves are nonstructural. The apex determines TL versus lumbar regional naming. Classic Types 5 and 6 use lumbar modifier C; the sagittal modifier still requires measured standing T5-T12 kyphosis. | Use the full geometry to support planning around the structural TL/L curve while retaining global coronal/sagittal balance, lowest-instrumented-level considerations, flexibility, rotation, maturity and goals. Type 5 neither mandates surgery nor prescribes a fusion construct. | Type 5 does not provide a type-specific probability of progression, decompensation, adjacent-segment disease or outcome. Serial Cobb change and skeletal maturity are essential for progression assessment. | Slattery and Verma 2018, PMC6259994, Table 1, curve apex definitions and Lumbar Spine Modifiers; Lenke et al. 2001, PMID 11507125. | ✓ |
| 6 | Type 6, thoracolumbar/lumbar-main thoracic | Thoracolumbar/lumbar-main thoracic pattern: the TL/L curve is structural and major, the main thoracic curve is also structural, and the proximal thoracic curve is nonstructural. The TL/L Cobb angle is at least 5 degrees greater than the MT angle, separating Type 6 from MT-major Type 3. Classic Type 6 pairs with lumbar modifier C and also requires a sagittal modifier. | Both structural MT and TL/L regions and their relative magnitudes must be carried into operative planning, but Type 6 does not itself determine whether or where to fuse. Integrate balance, flexibility, rotation, maturity, symptoms, neurologic findings and patient goals. | Type 6 is a deformity pattern rather than the sixth step of severity. The label alone does not quantify progression, imbalance, complication or outcome risk and should not be used as a prognosis. | Slattery and Verma 2018, PMC6259994, Table 1 and Curve Types discussion; Lenke et al. 2001, PMID 11507125. The 5-degree Type 3/6 major-curve boundary is retained in the structured map with explicit raw Cobb measurements. | ✓ |

### Per-category citations
- **1**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1 Curve Types, Structural Curves, Lumbar Spine Modifiers and Thoracic Sagittal Modifier; Lenke et al. 2001, PMID 11507125.
- **2**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1 and Structural Curves section, including PT sagittal structural criterion; Lenke et al. 2001, PMID 11507125.
- **3**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1 Curve Types and discussion of major versus structural curves; Lenke et al. 2001, PMID 11507125.
- **4**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1 Curve Types (Type 4 permits MT or TL/L major) and modifier sections; Lenke et al. 2001, PMID 11507125.
- **5**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1, curve apex definitions and Lumbar Spine Modifiers; Lenke et al. 2001, PMID 11507125.
- **6**: Slattery C, Verma K. Classifications in Brief: The Lenke Classification for Adolescent Idiopathic Scoliosis (2018) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6259994/ · Slattery and Verma 2018, PMC6259994, Table 1 and Curve Types discussion; Lenke et al. 2001, PMID 11507125. The 5-degree Type 3/6 major-curve boundary is retained in the structured map with explicit raw Cobb measurements.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-05-23 | revised | A correction replaced Figure 5 of the SRS-Lenke-Aubin 3D article because the lumbar apical vertebral rotation example had been inadequately rounded. | confirmed |
| 2025-12-16 | revised | The SRS-Lenke-Aubin 3D extension was published online, retaining the classic base and adding regional transverse-plane ORPD and AVR modifiers from 3D reconstructions. It is tracked separately from the classic code. | confirmed |
| 2001-08-01 | published | Lenke and colleagues published the classic three-component two-dimensional operative-AIS classification: curve type, lumbar modifier and thoracic sagittal modifier. | confirmed |
| 2001-01-01 | published | Lenke classification of adolescent idiopathic scoliosis published. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/lenke · API JSON: https://radcommons.laudos.ai/api/v1/systems/lenke · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Meyerding — Meyerding grading of spondylolisthesis

> Grades vertebral slip by percentage.

**Status:** current · **Organ:** Spine · **Issuing body:** Orthopedic consensus · **Version:** 1932 · **Year:** 1932

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: XR, MRI
- Primary source: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I (0-25%) | Anterior translation of the slipped vertebra measuring roughly 1% to 25% of the adjacent vertebral body width. A low-grade slip (Grade I-II = under 50%). | Nonoperative care is first-line for low-grade slips: activity modification, physical therapy/core strengthening, and analgesia. Surgery (decompression usually combined with fusion) is reserved for persistent pain refractory to conservative treatment, neurologic deficit, or progressive slip; only about 10%-15% of younger low-grade patients fail conservative management and need surgery. | Low-grade slips generally have a favorable prognosis with lower likelihood of progression than high-grade slips; most are managed successfully without surgery. | StatPearls NBK430767, Treatment/Management ('Nonoperative management is the first-line approach'; surgery for refractory pain, neurologic deficit, or progressive deformity; 'In low-grade cases, decompression, usually combined with fusion, is the standard surgical approach'; '10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment'). Grade I band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade I 0-25%). | ✓ |
| II | Grade II (25-50%) | Anterior translation of the slipped vertebra measuring roughly 26% to 50% of the adjacent vertebral body width. Still a low-grade slip (Grade I-II = under 50%). | As for Grade I: nonoperative management first-line, with decompression plus fusion reserved for refractory pain, neurologic deficit, or documented progression. The 50% slip boundary (between Grade II and III) marks the conventional transition from low-grade to high-grade and is a prognostically meaningful threshold. | Low-grade prognosis; lower progression risk than high-grade disease, though slips approaching the 50% threshold warrant monitoring for progression. | StatPearls NBK430767, Treatment/Management (same low-grade nonoperative-first, decompression+fusion approach); low-grade vs high-grade boundary at ~50% per Evaluation/management discussion. Grade II band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade II 25-50%). | ✓ |
| III | Grade III (50-75%) | Anterior translation of the slipped vertebra measuring roughly 51% to 75% of the adjacent vertebral body width. A high-grade slip (Grade III-V = over 50%). | High-grade slips are more likely to require surgery (decompression with instrumented fusion); reduction techniques are considered, particularly when there is an unbalanced/decompensated spinopelvic alignment. Nonoperative care may still be trialed for the asymptomatic or mildly symptomatic patient, but the surgical threshold is lower than for low-grade disease. | High-grade spondylolisthesis carries a more guarded prognosis owing to a higher likelihood of progression and of complications. | StatPearls NBK430767, Treatment/Management ('High-grade spondylolisthesis carries a more guarded prognosis due to the higher likelihood of progression and complications'; reduction 'strongly considered if a superimposed unbalanced spine is noted'). Grade III band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade III 50-75%). | ✓ |
| IV | Grade IV (75-100%) | Anterior translation of the slipped vertebra measuring roughly 76% to 100% of the adjacent vertebral body width. A high-grade slip (Grade III-V = over 50%). | High-grade management as for Grade III: instrumented decompression and fusion, with reduction considered for spinopelvic imbalance. Surgical correction of severe high-grade slips is technically demanding with higher complication rates. | Guarded prognosis with higher progression and complication risk characteristic of high-grade slips. | StatPearls NBK430767, Treatment/Management (high-grade guarded prognosis, reduction for unbalanced spine). Grade IV band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade IV 75-100%). | ✓ |
| V | Grade V, spondyloptosis | Slip greater than 100%, where the vertebra has fully translated off the one below it (spondyloptosis). The most severe high-grade slip. | Spondyloptosis is essentially a surgical problem: instrumented fusion with reduction or, in selected cases, vertebrectomy techniques are used to restore alignment. Carries the highest technical difficulty and complication profile. | Most guarded prognosis of the grades, with the greatest deformity, neurologic risk, and surgical complication potential. | StatPearls NBK430767, Treatment/Management (high-grade guarded prognosis and reduction considerations apply to the most severe slips). Grade V band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade V >100%). | ✓ |

### Per-category citations
- **I**: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis · StatPearls NBK430767, Treatment/Management ('Nonoperative management is the first-line approach'; surgery for refractory pain, neurologic deficit, or progressive deformity; 'In low-grade cases, decompression, usually combined with fusion, is the standard surgical approach'; '10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment'). Grade I band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade I 0-25%).
- **II**: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis · StatPearls NBK430767, Treatment/Management (same low-grade nonoperative-first, decompression+fusion approach); low-grade vs high-grade boundary at ~50% per Evaluation/management discussion. Grade II band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade II 25-50%).
- **III**: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis · StatPearls NBK430767, Treatment/Management ('High-grade spondylolisthesis carries a more guarded prognosis due to the higher likelihood of progression and complications'; reduction 'strongly considered if a superimposed unbalanced spine is noted'). Grade III band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade III 50-75%).
- **IV**: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis · StatPearls NBK430767, Treatment/Management (high-grade guarded prognosis, reduction for unbalanced spine). Grade IV band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade IV 75-100%).
- **V**: Meyerding HW. Spondylolisthesis (Meyerding grading) (1932) — https://en.wikipedia.org/wiki/Spondylolisthesis · StatPearls NBK430767, Treatment/Management (high-grade guarded prognosis and reduction considerations apply to the most severe slips). Grade V band corroborated by Wikipedia 'Spondylolisthesis', Severity (Grade V >100%).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/meyerding · API JSON: https://radcommons.laudos.ai/api/v1/systems/meyerding · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Modic — Modic vertebral endplate marrow changes

> Per-disc-level MRI phenotype of vertebral endplate-adjacent marrow signal: fibrovascular/edematous type 1, fatty type 2 and sclerotic type 3, including mixed patterns. It is a descriptive imaging classification, not proof of infection, a pain generator or a treatment indication.

**Status:** current · **Organ:** Spine · **Issuing body:** Modic et al. / ISSLS Degenerative Spinal Phenotypes Group · **Version:** 1988 types 1-3; ISSLS reporting recommendations and evidence through 2026 · **Year:** 1988

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Modic MT, Steinberg PM, Ross JS, et al.. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging (1988) — https://doi.org/10.1148/radiology.166.1.3336678
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify endplate-adjacent marrow per level from sequence-aware T1/T2 evidence, preserve mixed patterns and dangerous mimics, and never turn a Modic type into pain causality, infection exclusion or an autonomous treatment instruction.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Type 1, edematous or inflammatory | At a named disc/endplate level, marrow immediately adjacent to the endplate is low signal on conventional T1-weighted MRI and high signal on conventional non-fat-suppressed T2-weighted MRI relative to normal vertebral marrow. The tissue correlate is endplate disruption/fissuring with water-rich fibrovascular marrow replacement; map cranial/caudal endplate, distribution, extent and any mixed type 2 component. | Report a type 1 or mixed 1/2 phenotype with sequence adequacy and actively check for infection, acute Schmorl node, fracture, inflammatory disease and tumor when morphology or clinical context warrants. The Modic label does not select analgesia, rehabilitation, injection, surgery or antibiotics; suspected infection follows its own urgent diagnostic pathway. | Type 1 is an edematous/fibrovascular imaging phenotype, not proof of painful inflammation or occult infection. Pain associations across studies are inconsistent. The 2019 AIM trial found no clinically important one-year amoxicillin benefit, while a 2026 Cochrane synthesis found only low-certainty small short-term benefits in selected type-1-plus-disc-herniation patients and very uncertain harms; neither supports image-only prescribing. | Modic et al. 1988, DOI 10.1148/radiology.166.1.3336678, abstract/results for low T1/high T2 and fibrovascular tissue; Fields et al. 2019, PMC7205555, reporting recommendations; Herlin et al. 2018, PMC6070210, Results/Conclusions; Bråten et al. 2019, PMC6812614, primary outcome; Liu et al. 2026, DOI 10.1002/14651858.CD014221.pub2, Authors' conclusions. | ✓ |
| 2 | Type 2, fatty | Endplate-adjacent marrow is high signal on conventional T1-weighted MRI and isointense to slightly high signal on conventional non-fat-suppressed T2-weighted MRI, corresponding to fatty yellow-marrow replacement. Fat suppression can make the same tissue dark on fluid-sensitive imaging, so retain the actual sequence context and any mixed type 1 or type 3 component. | Describe the level, both adjacent endplates, extent and mixed pattern, with disc degeneration and endplate defects reported separately. Type 2 does not identify the symptomatic level or dictate conservative care, procedure or surgery; management requires clinical concordance and the complete spine examination. | Type 2 is a fatty degenerative marrow phenotype, not a calibrated stage of pain, disability or future deterioration. It can persist, coexist with type 1 or type 3, or change over time, and it neither excludes another pain generator nor supplies a treatment-response probability. | Modic et al. 1988, DOI 10.1148/radiology.166.1.3336678, abstract/results for high T1, iso/slightly high T2 and fatty replacement; Fields et al. 2019, PMC7205555, sections on sequence effects, mixed phenotypes, measurement and reporting; Herlin et al. 2018, PMC6070210, association limitations. | ✓ |
| 3 | Type 3, sclerotic | Endplate-adjacent marrow is low signal on both conventional T1-weighted and conventional non-fat-suppressed T2-weighted MRI, corresponding to subchondral sclerosis. Corroborating dense sclerosis on CT or radiographs supports the interpretation; low signal only on fat-suppressed T2/STIR is insufficient because fat is also suppressed there. | Report type 3 at the exact level with extent, endplate morphology and any mixed type 2 component. CT or radiographs may clarify sclerosis, but the type itself does not require intervention or identify a pain generator; address fracture, destructive lesion or other competing diagnosis on its own evidence. | Type 3 is an uncommon sclerotic phenotype, not a validated end-stage prognosis and not evidence that symptoms are irreversible. A pure or mixed type 3 category does not predict pain severity, fracture, cancer, progression rate or benefit from surgery. | Modic et al. 1988, Imaging of degenerative disk disease, DOI 10.1148/radiology.168.1.3289089, type 3 low-T1/low-T2 sclerotic pattern; Fields et al. 2019, PMC7205555, sequence/reporting recommendations and mixed phenotypes. | ✓ |

### Per-category citations
- **1**: Modic MT, Steinberg PM, Ross JS, et al.. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging (1988) — https://doi.org/10.1148/radiology.166.1.3336678 · Modic et al. 1988, DOI 10.1148/radiology.166.1.3336678, abstract/results for low T1/high T2 and fibrovascular tissue; Fields et al. 2019, PMC7205555, reporting recommendations; Herlin et al. 2018, PMC6070210, Results/Conclusions; Bråten et al. 2019, PMC6812614, primary outcome; Liu et al. 2026, DOI 10.1002/14651858.CD014221.pub2, Authors' conclusions.
- **2**: Modic MT, Steinberg PM, Ross JS, et al.. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging (1988) — https://doi.org/10.1148/radiology.166.1.3336678 · Modic et al. 1988, DOI 10.1148/radiology.166.1.3336678, abstract/results for high T1, iso/slightly high T2 and fatty replacement; Fields et al. 2019, PMC7205555, sections on sequence effects, mixed phenotypes, measurement and reporting; Herlin et al. 2018, PMC6070210, association limitations.
- **3**: Modic MT, Steinberg PM, Ross JS, et al.. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging (1988) — https://doi.org/10.1148/radiology.166.1.3336678 · Modic et al. 1988, Imaging of degenerative disk disease, DOI 10.1148/radiology.168.1.3289089, type 3 low-T1/low-T2 sclerotic pattern; Fields et al. 2019, PMC7205555, sequence/reporting recommendations and mixed phenotypes.

## Cross-references
- _shared boundary_ → [Pfirrmann — Pfirrmann grading of lumbar disc degeneration](https://radcommons.laudos.ai/systems/pfirrmann.md) — Both grade degenerative lumbar spine MRI: Modic for endplate and marrow changes, Pfirrmann for disc degeneration.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-01 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 1988-07-01 | revised | The companion imaging paper described the low-T1 and low-T2 sclerotic type 3 phenotype, completing the commonly used three-type map. | confirmed |
| 1988-01-01 | published | Modic and colleagues published the original type 1 and type 2 vertebral endplate marrow signal phenotypes. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/modic · API JSON: https://radcommons.laudos.ai/api/v1/systems/modic · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Pfirrmann — Pfirrmann grading of lumbar disc degeneration

> Per-disc lumbar MRI grading that combines T2 structure, nucleus-annulus distinction, signal intensity and disc height; it describes degeneration morphology and does not classify herniation, symptoms or treatment need.

**Status:** current · **Organ:** Spine · **Issuing body:** Pfirrmann et al. · **Version:** original five-grade system (2001) · **Year:** 2001

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Apply the original four-feature matrix per lumbar disc. Preserve discordant features and version identity; never turn a morphology grade into a pain diagnosis or treatment command.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | Grade I: homogeneous, bright-white disc structure; a clear nucleus pulposus-annulus fibrosus distinction; T2 signal hyperintense and isointense to cerebrospinal fluid; and normal intervertebral-disc height. | Report Grade I with its four supporting features at the specific lumbar level. The grade does not direct treatment; correlate symptoms and any intervention decision with the neurologic examination and separate structural findings. | This is the least degenerated morphology in the original five-grade system, but it supplies no probability of pain, future degeneration, neurologic deficit or need for intervention and does not exclude another pain generator. | Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade I; Methods specify grading on T2-weighted midsagittal images; Discussion defines the system as gross disc morphology rather than a symptom or treatment scale. | ✓ |
| II | Grade II | Grade II: inhomogeneous disc structure, with or without horizontal bands; the nucleus-annulus distinction remains clear; T2 signal remains hyperintense and isointense to cerebrospinal fluid; and disc height remains normal. | Document the inhomogeneity or horizontal bands while preserving the normal height and high signal that distinguish Grade II. No surveillance, procedure or operation follows from Grade II alone; correlate clinically and report other abnormalities separately. | Grade II denotes early morphologic change relative to Grade I, not a calibrated risk stratum. The original publication gives no per-grade probability of symptoms, progression, work limitation or later treatment. | Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade II; Results and Discussion describe reliability and note that disagreements were relatively frequent at the I-II boundary. | ✓ |
| III | Grade III | Grade III: inhomogeneous gray disc structure; an unclear nucleus-annulus distinction; intermediate T2 signal; and disc height that is normal to slightly decreased. | Report every defining feature and the lumbar level, then describe herniation, stenosis, endplate change and neural effect independently. Grade III alone neither establishes a symptomatic pain generator nor selects conservative or operative care. | Grade III is an intermediate morphologic category. The five-grade scale does not attach a patient-specific likelihood of pain, progression, instability, neurologic compromise or intervention to this label. | Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade III; Discussion states that height does not discriminate Grade III from Grade IV and that the system assesses gross morphology. | ✓ |
| IV | Grade IV | Grade IV: inhomogeneous gray-to-black disc structure; loss of the nucleus-annulus distinction; intermediate-to-hypointense T2 signal; and disc height ranging from normal to moderately decreased, without the collapsed space required for Grade V. | Describe the advanced morphologic features and preserve the actual disc-height category. Treatment still depends on symptoms, neurologic findings, instability, herniation and stenosis; a dark Grade IV disc is not by itself an indication for a procedure. | Grade IV denotes advanced degeneration morphology but is not a prognosis. The original system does not quantify pain, progression, nerve injury or surgical probability, and height overlap with Grade III limits single-feature inference. | Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade IV; Discussion states that height is not discriminative for III versus IV and is important for distinguishing IV from V. | ✓ |
| V | Grade V | Grade V: inhomogeneous black disc structure; lost nucleus-annulus distinction; hypointense T2 signal; and a collapsed disc space. All four features should support end-stage morphology rather than assigning V from reduced height alone. | Report collapse and the complete feature pattern, then separately describe neural compression, deformity, instability and postoperative status. Grade V alone does not mandate surgery; exclude congenital or transitional-disc hypoplasia when height and signal conflict. | This is the most advanced morphology in the original five-grade system, but it remains an ordinal imaging label without an individual probability of pain, disability, neurologic deficit, progression or treatment response. | Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade V; Discussion explains height as the IV-V discriminator and describes a sacralized transitional level misgraded V when marked smallness conflicted with Grade-II-like signal. | ✓ |

### Per-category citations
- **I**: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/ · Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade I; Methods specify grading on T2-weighted midsagittal images; Discussion defines the system as gross disc morphology rather than a symptom or treatment scale.
- **II**: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/ · Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade II; Results and Discussion describe reliability and note that disagreements were relatively frequent at the I-II boundary.
- **III**: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/ · Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade III; Discussion states that height does not discriminate Grade III from Grade IV and that the system assesses gross morphology.
- **IV**: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/ · Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade IV; Discussion states that height is not discriminative for III versus IV and is important for distinguishing IV from V.
- **V**: Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration (2001) — https://pubmed.ncbi.nlm.nih.gov/11568697/ · Pfirrmann et al., Spine 2001;26:1873-1878, Table 1, Grade V; Discussion explains height as the IV-V discriminator and describes a sacralized transitional level misgraded V when marked smallness conflicted with Grade-II-like signal.

## Cross-references
- _shared boundary_ → [Modic — Modic vertebral endplate marrow changes](https://radcommons.laudos.ai/systems/modic.md) — Complementary to Modic endplate changes when grading lumbar degeneration.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2001-09-01 | published | Pfirrmann disc degeneration grading published in Spine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/pfirrmann · API JSON: https://radcommons.laudos.ai/api/v1/systems/pfirrmann · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# SINS — Spinal Instability Neoplastic Score

> Scores six components (one clinical, five radiographic) to grade the mechanical instability of a neoplastic spinal segment and prompt surgical referral.

**Status:** current · **Organ:** Spine · **Issuing body:** Spine Oncology Study Group · **Version:** 2010 · **Year:** 2010

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT, MRI
- Primary source: Fisher CG, DiPaola CP, Ryken TC, et al.; review by Hussain I, Barzilai O, et al.. A novel classification system for spinal instability in neoplastic disease (SINS), reproduced in Classifications in Brief (2010) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6907315/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Score every involved segment separately. Preserve the clinical pain input, return all six component scores, and treat the total as an instability-referral aid rather than an automatic procedure selector.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0-6 | Stable (0-6) | Total SINS of 0-6 after scoring all six elements for one involved lesion or spinal segment: location, mechanical pain, bone-lesion quality, alignment, vertebral-body collapse, and posterolateral-element involvement. Every lesion is scored separately when multiple levels are involved. | The SINS referral interpretation is stable; referral specifically for evaluation of neoplastic spinal instability is not generally required by this score alone. Neurologic deficit, epidural compression and other urgent clinical findings remain separate assessments and can supersede the score. | Stable SINS category. This is a qualitative mechanical-stability classification, not a calibrated probability of fracture, neurologic deterioration, survival or treatment response. | Fisher et al., Spine 2010, PMID 20562730, six-component construction; Fourney et al., JCO 2011, PMID 21709187, validated 0-6 stable band; Hussain et al., PMC6907315, Description and Interpretation sections, including separate scoring for each lesion. | ✓ |
| 7-12 | Potentially unstable (7-12) | Total SINS of 7-12 after the same complete six-component, per-lesion calculation. The validated label is potentially unstable (also described as indeterminate stability), not a specific operative diagnosis. | Refer for spine-surgical or spine-oncology evaluation of possible mechanical instability. The score does not choose between observation, bracing, cement augmentation, fixation, radiotherapy or another treatment; that decision requires neurologic, oncologic and systemic context. | Potentially unstable category with greater concern for tumor-related mechanical instability than 0-6. The band does not provide a patient-specific event probability and contains clinically heterogeneous component combinations. | Fourney et al., JCO 2011, PMID 21709187, 7-12 potentially unstable category; Hussain et al., PMC6907315, Interpretation and Limitations: scores 7-18 warrant referral, while SINS does not itself provide treatment recommendations. | ✓ |
| 13-18 | Unstable (13-18) | Total SINS of 13-18 after the complete six-component, per-lesion calculation. High totals can reflect junctional location, mechanical pain, lytic destruction, translation or deformity, collapse, and bilateral posterolateral-element involvement in different combinations. | Refer promptly for specialist evaluation of mechanical instability. SINS identifies an unstable category but does not prescribe a specific operation or override neurologic compression, tumor biology, prognosis, prior treatment, bone quality, systemic fitness or patient goals. | Unstable SINS category and the highest qualitative concern for neoplastic mechanical instability. It is not a calibrated individual probability of collapse, neurologic injury, mortality or benefit from surgery. | Fourney et al., JCO 2011, PMID 21709187, 13-18 unstable category; Fisher et al., Spine 2010, PMID 20562730, use in surgical-consultation decisions; Hussain et al., PMC6907315, Interpretation and Limitations. | ✓ |

### Per-category citations
- **0-6**: Fisher CG, DiPaola CP, Ryken TC, et al.; review by Hussain I, Barzilai O, et al.. A novel classification system for spinal instability in neoplastic disease (SINS), reproduced in Classifications in Brief (2010) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6907315/ · Fisher et al., Spine 2010, PMID 20562730, six-component construction; Fourney et al., JCO 2011, PMID 21709187, validated 0-6 stable band; Hussain et al., PMC6907315, Description and Interpretation sections, including separate scoring for each lesion.
- **7-12**: Fisher CG, DiPaola CP, Ryken TC, et al.; review by Hussain I, Barzilai O, et al.. A novel classification system for spinal instability in neoplastic disease (SINS), reproduced in Classifications in Brief (2010) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6907315/ · Fourney et al., JCO 2011, PMID 21709187, 7-12 potentially unstable category; Hussain et al., PMC6907315, Interpretation and Limitations: scores 7-18 warrant referral, while SINS does not itself provide treatment recommendations.
- **13-18**: Fisher CG, DiPaola CP, Ryken TC, et al.; review by Hussain I, Barzilai O, et al.. A novel classification system for spinal instability in neoplastic disease (SINS), reproduced in Classifications in Brief (2010) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6907315/ · Fourney et al., JCO 2011, PMID 21709187, 13-18 unstable category; Fisher et al., Spine 2010, PMID 20562730, use in surgical-consultation decisions; Hussain et al., PMC6907315, Interpretation and Limitations.

## Cross-references
- _shared boundary_ → [Bilsky ESCC — Epidural spinal cord compression (ESCC / Bilsky) scale](https://radcommons.laudos.ai/systems/bilsky-escc.md) — SINS addresses instability; the ESCC scale addresses epidural cord compression in the same metastatic spine assessment.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2010-10-01 | published | Spinal Instability Neoplastic Score published in Spine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/sins · API JSON: https://radcommons.laudos.ai/api/v1/systems/sins · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# SLIC — Subaxial cervical spine Injury Classification and severity scale

> Scores injury morphology, discoligamentous complex integrity, and neurologic status to grade subaxial cervical spine trauma and guide operative versus nonoperative management.

**Status:** current · **Organ:** Spine · **Issuing body:** Spine Trauma Study Group · **Version:** 2007 · **Year:** 2007

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: CT, MRI
- Primary source: Vaccaro AR, Hulbert RJ, Patel AA, et al.; Spine Trauma Study Group. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex (2007) — https://pubmed.ncbi.nlm.nih.gov/17906580/
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Decision logic
Return every component and modifier instead of only the total. Keep score 4 explicitly equivocal and never infer the neurologic examination from CT or MRI.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| <=3 | Nonoperative (3 or less) | Total SLIC score of 0-3 for an acute subaxial cervical injury after adding the highest-severity morphology (0-4), discoligamentous-complex integrity (0-2), neurologic status (0-3), and the +1 persistent-cord-compression modifier when applicable. | The SLIC authors support nonoperative management for scores of 3 or less. This is a recommendation band rather than an automatic disposition; neurologic trajectory, confounders, comorbidities, patient preference and treating-spine-team judgment still apply. | Lower SLIC severity band. The score conveys relative injury severity and treatment guidance but is not a calibrated probability of instability, neurologic decline or failure of nonoperative care. | Vaccaro et al., Spine 2007, PMID 17906580 and DOI 10.1097/BRS.0b013e3181557b92, original score and treatment thresholds; Whang et al., PMC3032869, Table 2 and treatment recommendations; SLICS summary PMC7491911, Table 2. | ✓ |
| 4 | Equivocal (4) | Total SLIC score of exactly 4 from the same morphology, discoligamentous-complex and neurologic components, including the cord-compression modifier when it applies. | Intentionally equivocal: either nonoperative or operative management may be appropriate. The decision must integrate the exact component pattern, neurologic findings, confounders, patient preference, comorbidity and surgeon judgment rather than rounding the score into an adjacent band. | Indeterminate treatment-guidance band. Different component combinations can produce the same total, so the number alone does not quantify an individual adverse-event probability. | Whang et al., PMC3032869, treatment-threshold discussion; SLICS summary PMC7491911, Table 2 and text: score 4 is indeterminate and requires treating-surgeon discretion. | ✓ |
| >=5 | Operative (5 or more) | Total SLIC score of 5-10 from the complete component sum. Higher totals are driven by distraction or rotation/translation morphology, disrupted discoligamentous complex, neurologic injury, and/or persistent cord compression with deficit. | The SLIC authors support operative management for scores of 5 or more. The total does not independently select an approach, levels, decompression or construct; those require the injury pattern, neurologic status, patient factors and specialist judgment. | Higher SLIC severity band and stronger author support for operative treatment, but not a calibrated individual probability of instability, neurologic outcome, morbidity or surgical benefit. | Vaccaro et al., Spine 2007, PMID 17906580, original threshold-based treatment guidance; Whang et al., PMC3032869, Table 2 and treatment discussion; SLICS summary PMC7491911. | ✓ |

### Per-category citations
- **<=3**: Vaccaro AR, Hulbert RJ, Patel AA, et al.; Spine Trauma Study Group. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex (2007) — https://pubmed.ncbi.nlm.nih.gov/17906580/ · Vaccaro et al., Spine 2007, PMID 17906580 and DOI 10.1097/BRS.0b013e3181557b92, original score and treatment thresholds; Whang et al., PMC3032869, Table 2 and treatment recommendations; SLICS summary PMC7491911, Table 2.
- **4**: Vaccaro AR, Hulbert RJ, Patel AA, et al.; Spine Trauma Study Group. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex (2007) — https://pubmed.ncbi.nlm.nih.gov/17906580/ · Whang et al., PMC3032869, treatment-threshold discussion; SLICS summary PMC7491911, Table 2 and text: score 4 is indeterminate and requires treating-surgeon discretion.
- **>=5**: Vaccaro AR, Hulbert RJ, Patel AA, et al.; Spine Trauma Study Group. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex (2007) — https://pubmed.ncbi.nlm.nih.gov/17906580/ · Vaccaro et al., Spine 2007, PMID 17906580, original threshold-based treatment guidance; Whang et al., PMC3032869, Table 2 and treatment discussion; SLICS summary PMC7491911.

## Cross-references
- _shared boundary_ → [Anderson-D'Alonzo — Anderson and D'Alonzo classification of odontoid fractures](https://radcommons.laudos.ai/systems/anderson-dalonzo.md) — Cervical trauma systems: Anderson-D'Alonzo classifies odontoid (C2) fractures, SLIC scores subaxial (C3-C7) injuries.
- _shared boundary_ → [TLICS — Thoracolumbar Injury Classification and Severity score](https://radcommons.laudos.ai/systems/tlics.md) — SLIC adapts the TLICS framework (morphology, ligamentous/neural status, severity score) to the subaxial cervical spine.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2007-09-01 | published | Subaxial cervical spine injury classification published in Spine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/slic · API JSON: https://radcommons.laudos.ai/api/v1/systems/slic · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Schizas — Schizas morphological grading of lumbar central canal stenosis

> Grades degenerative lumbar central canal narrowing at each level by cauda-equina rootlet, CSF and posterior epidural-fat morphology on axial T2 MRI. It does not grade foraminal stenosis, diagnose symptomatic lumbar stenosis or select surgery by itself.

**Status:** current · **Organ:** Spine · **Issuing body:** Schizas et al. / spine imaging literature · **Version:** 2010 original morphology; current clinical-correlation limits · **Year:** 2010

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: MRI
- Primary source: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Grade every relevant lumbar level from axial T2 morphology. Keep central, lateral-recess and foraminal disease separate, preserve ungradable and adjacent-grade states, and never use the grade alone to diagnose symptomatic stenosis or choose surgery.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A1 | Grade A1, no/minor stenosis, rootlets dorsal occupying less than half the sac | On an adequate axial T2 image through the evaluated lumbar central canal level, cerebrospinal fluid remains clearly visible and the cauda-equina rootlets lie dorsally while occupying less than half of the dural-sac area. | Report A1 at the named lumbar level and describe lateral-recess, foraminal and causative degenerative findings separately. This morphology alone neither establishes symptomatic lumbar stenosis nor determines conservative, injection or surgical care. | A1 belongs to broad grade A (no or minor central stenosis in the original morphology). Grade has weak/inconsistent correlation with symptoms and postoperative outcome, so it cannot exclude a clinically responsible dynamic or noncentral lesion. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920: dorsal rootlets occupying less than half of dural sac; Yang et al. 2023, PMC10039594, Results/Discussion for limited symptom and outcome correlation. | ✓ |
| A2 | Grade A2, rootlets dorsal in horseshoe configuration | On axial T2 MRI, cerebrospinal fluid remains clearly visible and the rootlets lie dorsally in contact with the dura in a horseshoe configuration. The horseshoe morphology, not a numeric area cutoff, distinguishes A2. | Report A2 per level with image adequacy and the separate compartmental findings. A1-A4 are morphological subtypes within broad grade A and must not be converted into different treatment tiers without clinical correlation. | A2 does not predict pain, walking tolerance, neurologic deficit or surgical benefit. Static supine morphology can underrepresent dynamic narrowing, and reader training affects reproducibility. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for dorsal rootlets touching dura in a horseshoe; Ko et al. 2020, PMC7252624, reliability analysis; JOA guideline DOI 10.1016/j.jos.2022.03.013 for clinical-imaging correlation. | ✓ |
| A3 | Grade A3, rootlets dorsal occupying more than half the sac | On axial T2 MRI, cerebrospinal fluid remains clearly visible and the rootlets lie dorsally while occupying more than half of the dural-sac area. If occupancy near one half cannot be judged, report A1-versus-A3 uncertainty. | Use A3 as a per-level central-canal morphology and document symptoms, neurologic findings and responsible-level concordance outside the score. It does not prescribe surveillance, injection or decompression. | The increased rootlet occupancy is a morphology descriptor rather than a validated patient-level prognosis. Symptoms can be severe with lesser morphology or absent with greater narrowing, and the scale does not evaluate foraminal disease. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for dorsal rootlets occupying more than half; Yang et al. 2023, PMC10039594, correlation analyses and limitations. | ✓ |
| A4 | Grade A4, rootlets central occupying most of the sac | On axial T2 MRI, cerebrospinal fluid remains clearly visible and the rootlets lie centrally while occupying the majority of the dural-sac area. Central position differentiates A4 from the dorsal A1-A3 patterns. | Report the A4 morphology at its exact level and preserve separate lateral-recess and foraminal assessments. Do not infer a distinct intervention threshold merely because A4 is the last A subtype. | A4 is not an ordinal treatment step between A3 and B; all A subtypes retain visible cerebrospinal fluid. It cannot independently establish symptom causality, future deterioration or likely surgical response. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for central rootlets occupying most of the sac; Yang et al. 2023, PMC10039594, outcome-correlation limitations. | ✓ |
| B | Grade B, moderate, rootlets fill the sac but still individualizable | Moderate central stenosis morphology: rootlets occupy the entire dural sac but remain individually recognizable, with some residual cerebrospinal-fluid signal producing a grainy appearance. Loss of individual rootlet recognition moves the boundary toward C/D. | Report grade B per lumbar level, the degenerative cause, and other stenotic compartments. Clinical diagnosis and care require symptom pattern, examination and concordance; B alone does not favor or exclude surgery. | The original cohort grouped A/B as less associated with conservative-treatment failure than C/D, but it was small and clinically selected. Later work shows limited correlation with symptoms and postoperative outcomes, so this is not an individual risk estimate. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1, pp. 1920-1922 for individualized rootlets, grainy CSF and cohort associations; Yang et al. 2023, PMC10039594, Results/Discussion for modern correlation limits. | ✓ |
| C | Grade C, severe, no rootlets seen, posterior epidural fat present | Severe central stenosis morphology: no individual rootlets are recognizable and no cerebrospinal-fluid signal is visible, producing a homogeneous gray sac, while posterior epidural fat remains visible. Posterior fat is the required C-versus-D discriminator. | Surface grade C and any neurologic red flags promptly, but choose care only after clinical syndrome, examination, responsible level, comorbidity and patient goals are integrated. C is not an automatic decompression indication. | C/D were strongly associated with conservative-treatment failure in the original selected cohort (reported odds ratio 29.8), but grade was unrelated to baseline disability or surgical result there, and modern studies find weak or no outcome correlation. Do not individualize that cohort odds ratio. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and pp. 1920-1923 for absent CSF/rootlet recognition, retained posterior fat, odds ratio and outcome limits; Yang et al. 2023, PMC10039594, correlation and surgical-outcome analyses. | ✓ |
| D | Grade D, extreme, no rootlets and no posterior epidural fat | Extreme central stenosis morphology: no individual rootlets and no cerebrospinal-fluid signal are recognizable, and posterior epidural fat is also no longer visible. If posterior fat cannot be evaluated technically, report C-versus-D uncertainty rather than guessing. | Report grade D at the named level and communicate urgent neurologic findings directly, while retaining clinical decision-making outside the score. D alone does not determine emergency status, decompression, fusion or prognosis. | D is the most compressed morphology in this scale and shared the original C/D association with failed conservative care, but neither the original nor later evidence validates a deterministic symptom or surgical-outcome prediction from grade D alone. | Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and pp. 1920-1923 for absent rootlets/CSF/posterior fat and cohort limitations; Ko et al. 2020, PMC7252624, reader reliability; Yang et al. 2023, PMC10039594, clinical and outcome limits. | ✓ |

### Per-category citations
- **A1**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920: dorsal rootlets occupying less than half of dural sac; Yang et al. 2023, PMC10039594, Results/Discussion for limited symptom and outcome correlation.
- **A2**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for dorsal rootlets touching dura in a horseshoe; Ko et al. 2020, PMC7252624, reliability analysis; JOA guideline DOI 10.1016/j.jos.2022.03.013 for clinical-imaging correlation.
- **A3**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for dorsal rootlets occupying more than half; Yang et al. 2023, PMC10039594, correlation analyses and limitations.
- **A4**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and p. 1920 for central rootlets occupying most of the sac; Yang et al. 2023, PMC10039594, outcome-correlation limitations.
- **B**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1, pp. 1920-1922 for individualized rootlets, grainy CSF and cohort associations; Yang et al. 2023, PMC10039594, Results/Discussion for modern correlation limits.
- **C**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and pp. 1920-1923 for absent CSF/rootlet recognition, retained posterior fat, odds ratio and outcome limits; Yang et al. 2023, PMC10039594, correlation and surgical-outcome analyses.
- **D**: Schizas C, Theumann N, Burn A, et al.. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on MR images (2010) — https://pubmed.ncbi.nlm.nih.gov/20671589/ · Schizas et al. 2010, DOI 10.1097/BRS.0b013e3181d359bd, Figure 1 and pp. 1920-1923 for absent rootlets/CSF/posterior fat and cohort limitations; Ko et al. 2020, PMC7252624, reader reliability; Yang et al. 2023, PMC10039594, clinical and outcome limits.

## Cross-references
- _shared boundary_ → [Pfirrmann — Pfirrmann grading of lumbar disc degeneration](https://radcommons.laudos.ai/systems/pfirrmann.md) — Degenerative lumbar MRI: Schizas grades central canal stenosis, Pfirrmann grades disc degeneration.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2010-10-01 | published | Morphological grading of lumbar spinal stenosis published in Spine. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/schizas · API JSON: https://radcommons.laudos.ai/api/v1/systems/schizas · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# TLICS — Thoracolumbar Injury Classification and Severity score

> Per-patient thoracolumbar-trauma score using the highest morphology at the most severely involved level, posterior-ligamentous-complex integrity and the clinical neurologic examination. Totals of 3 or less, 4 and 5 or more are treatment-guidance bands rather than absolute orders or calibrated paralysis, mortality or deformity probabilities.

**Status:** current · **Organ:** Spine · **Issuing body:** Spine Trauma Study Group · **Version:** Original 2005 TLICS; evidence and imaging-use boundaries reviewed through 2021 · **Year:** 2005

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Vaccaro AR, Lehman RA, Hurlbert RJ, et al.. A new classification of thoracolumbar injuries (TLICS) (2005) — https://doi.org/10.1097/01.brs.0000182986.43345.cb
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Score the highest morphology at the most severely injured level, PLC status and a reliable clinical neurologic examination. Preserve component uncertainty, avoid multilevel summation and cervical modifiers, and treat the thresholds as guidance rather than prognosis or an autonomous order.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| <=3 | TLICS 3 or less, nonoperative candidate | TLICS total 3 or less. At the most severely involved thoracolumbar level, add only the highest morphology value (compression 1, burst 2, translation/rotation 3 or distraction 4), PLC status (intact 0, suspected/indeterminate 2 or injured 3) and the reliable clinical neurologic category (intact 0, nerve root 2, complete cord/conus 2, incomplete cord/conus 3 or cauda equina 3). Describe all injured levels but do not sum them. | The original algorithm supports nonoperative treatment as a candidate pathway, not an absolute command. Progressive neurologic deficit, open injury, deformity, ankylosing conditions, osteoporosis, polytrauma, soft tissues, comorbidity, patient goals and local expertise remain outside the total and can change care. | A lower total represents fewer points from disruptive morphology, PLC concern and neurologic injury within TLICS, but it is not a calibrated probability of stability, paralysis, deformity, nonunion, treatment failure or mortality. A low score cannot replace the actual examination and imaging findings. | Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, component and treatment tables; Lee et al., PMC2779435, score construction, thresholds and caveats; Jiménez-Almonte et al., PMC6263590, PLC limitations; WFNS 2021, PMC8752700, CT/MRI context. | ✓ |
| 4 | TLICS 4, operative or nonoperative candidate | TLICS total exactly 4, calculated from one highest morphology score at the most severely involved level plus PLC status and a clinical neurologic examination. If morphology, PLC or neurologic status is unresolved, preserve the component uncertainty and conditional score range rather than forcing exactly 4. | Either operative or nonoperative treatment may be appropriate; the original framework explicitly leaves this band to clinical judgment. Make the decisive morphology, PLC certainty, neurologic state, patient modifiers and competing injuries visible instead of relabeling 4 as automatically stable or unstable. | The intermediate decision band is not a validated risk percentage. Multiple clinically different component combinations yield 4, so the number alone does not predict neurologic recovery, late kyphosis, treatment failure, reoperation or mortality. | Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, treatment recommendation table; Lee et al., DOI 10.1007/s00776-005-0956-y, operative versus nonoperative discretion and caveats; Magnusson et al., PMC5919222, description and limitations. | ✓ |
| >=5 | TLICS 5 or more, operative candidate | TLICS total 5 or more, calculated from the single highest morphology at the most severely involved level, PLC status and the clinical neurologic examination. Do not add multiple morphology patterns, multiple levels or the SLIC ongoing-cord-compression modifier. | The original algorithm supports operative treatment as a candidate pathway, but the total does not choose timing, approach, decompression, levels or instrumentation and is not absolute. Integrate neurologic urgency, mechanical findings, polytrauma, soft tissues, comorbidity and patient-specific constraints. | A higher total reflects more points from structural disruption, PLC injury and/or neurologic deficit, not a patient-specific probability of paralysis, mortality or late deformity. The exact components carry more clinical meaning than the band alone. | Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, scoring and operative-candidate threshold; Lee et al., PMC2779435, components and caveats; Jiménez-Almonte et al., PMC6263590, reliability limitations; WFNS 2021, PMC8752700, contemporary imaging context. | ✓ |

### Per-category citations
- **<=3**: Vaccaro AR, Lehman RA, Hurlbert RJ, et al.. A new classification of thoracolumbar injuries (TLICS) (2005) — https://doi.org/10.1097/01.brs.0000182986.43345.cb · Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, component and treatment tables; Lee et al., PMC2779435, score construction, thresholds and caveats; Jiménez-Almonte et al., PMC6263590, PLC limitations; WFNS 2021, PMC8752700, CT/MRI context.
- **4**: Vaccaro AR, Lehman RA, Hurlbert RJ, et al.. A new classification of thoracolumbar injuries (TLICS) (2005) — https://doi.org/10.1097/01.brs.0000182986.43345.cb · Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, treatment recommendation table; Lee et al., DOI 10.1007/s00776-005-0956-y, operative versus nonoperative discretion and caveats; Magnusson et al., PMC5919222, description and limitations.
- **>=5**: Vaccaro AR, Lehman RA, Hurlbert RJ, et al.. A new classification of thoracolumbar injuries (TLICS) (2005) — https://doi.org/10.1097/01.brs.0000182986.43345.cb · Vaccaro et al., Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, scoring and operative-candidate threshold; Lee et al., PMC2779435, components and caveats; Jiménez-Almonte et al., PMC6263590, reliability limitations; WFNS 2021, PMC8752700, contemporary imaging context.

## Cross-references
- _shared boundary_ → [AO Spine TL — AO Spine thoracolumbar injury classification and TL AOSIS](https://radcommons.laudos.ai/systems/aospine-tl.md) — TLICS uses its own morphology, PLC and neurologic point table with 3/4/5 thresholds. AO Spine assigns an exact A0-A4, B1-B3 or C morphology plus N and M codes and a separate TL AOSIS total; no category or total crosswalk is valid.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2021-12-01 | revised | WFNS recommendations retained TLICS and AO Spine as valid thoracolumbar-trauma frameworks and supplied CT/MRI context; they did not create a new TLICS version or make its thresholds absolute. | confirmed |
| 2005-10-15 | published | The Spine Trauma Study Group published the original TLICS components, scores and treatment-guidance thresholds. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/tlics · API JSON: https://radcommons.laudos.ai/api/v1/systems/tlics · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# AAST Spleen — AAST splenic injury scale

> Grades splenic injury severity on CT.

**Status:** current · **Organ:** Spleen · **Issuing body:** American Association for the Surgery of Trauma · **Version:** 2018 · **Year:** 2018

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT
- Primary source: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Grade I | Minor injury: subcapsular hematoma covering less than 10% of the splenic surface area, and/or a parenchymal laceration under 1 cm deep, and/or a simple capsular tear. | Low-grade injury (WSES minor, grades I-II): nonoperative management is the standard of care in hemodynamically stable patients - observation with serial vitals/hemoglobin. Splenic angioembolization is reserved for a contrast blush/vascular injury; surgery only for hemodynamic instability or failed NOM. | Lowest-risk tier: nonoperative management succeeds in roughly 95-99% of low-grade injuries; overall NOM success across blunt splenic trauma is up to about 80%. | Management grouping (low-grade I-II = NOM, embolization for blush) per WSES spleen classification PMC6580626 and StatPearls 'Splenic Injury' NBK441993; NOM success up to 80% overall per NBK441993. | ✓ |
| II | Grade II | Subcapsular hematoma involving 10-50% of surface area, or an intraparenchymal hematoma smaller than 5 cm; and/or a parenchymal laceration 1-3 cm deep. | Low-grade injury (WSES minor, grades I-II): nonoperative management in stable patients with serial monitoring; splenic artery angioembolization when CT shows a contrast blush, pseudoaneurysm, or AV fistula. Operative management (splenectomy/splenorrhaphy) reserved for instability or NOM failure. | Low-risk tier with high NOM success; a contrast blush raises failure risk - low-grade injuries with active extravasation may fail NOM in up to ~20% if not embolized. | Low-grade NOM/embolization grouping per WSES PMC6580626 and StatPearls NBK441993; ~20% NOM failure with blush per EAST multicenter study PMC10921525. | ✓ |
| III | Grade III | Subcapsular hematoma exceeding 50% of surface area, or a ruptured subcapsular/intraparenchymal hematoma 5 cm or larger; and/or a parenchymal laceration deeper than 3 cm. | High-grade injury (WSES moderate, grade III): nonoperative management still attempted in stable patients, but splenic angioembolization is used liberally - grade III carries the highest embolization rate. Operative management for instability, peritonitis, or NOM failure. | Higher-risk tier: NOM failure and the need for intervention rise with grade; grade III had the highest angioembolization rate (~39%) in the WSES validation cohort. | Grade III = angioembolization candidate / highest AE rate (~38.9%) per WSES PMC6580626; embolization recommended grade III and above per StatPearls NBK441993. | ✓ |
| IV | Grade IV | Any injury accompanied by a splenic vascular injury (pseudoaneurysm or arteriovenous fistula) or active bleeding that remains confined within the splenic capsule; or a parenchymal laceration involving segmental or hilar vessels that produces more than 25% devascularization of the spleen. | High-grade injury (WSES severe, grades IV-V): operative management predominates - in stable patients NOM with angioembolization may be tried at high-acuity centers, but most undergo surgery (splenectomy). Unstable patients go directly to laparotomy. | High-risk tier: AAST grade greater than III had ~77% operative-management rate in the WSES cohort; grade and hemodynamic instability drive higher NOM failure and mortality. | AAST greater-than-III ~77.1% operative rate per WSES PMC6580626; high-grade = surgery-predominant per StatPearls NBK441993. | ✓ |
| V | Grade V | Any injury with a splenic vascular injury where active bleeding extends beyond the spleen into the peritoneum; or a shattered spleen. | High-grade injury (WSES severe, grades IV-V): operative management (usually total splenectomy) is the rule, particularly with hemodynamic instability or a shattered spleen; damage-control surgery for the unstable patient. Highly selected stable grade V may attempt NOM with embolization at major trauma centers. | Highest-risk tier: grade V is an independent predictor of NOM failure and mortality; the great majority require operative management. | Grade V predicts NOM failure/mortality and operative management per WSES PMC6580626 and StatPearls NBK441993; high-grade operative predominance (~77% for AAST greater-than-III). | ✓ |

### Per-category citations
- **I**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Management grouping (low-grade I-II = NOM, embolization for blush) per WSES spleen classification PMC6580626 and StatPearls 'Splenic Injury' NBK441993; NOM success up to 80% overall per NBK441993.
- **II**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Low-grade NOM/embolization grouping per WSES PMC6580626 and StatPearls NBK441993; ~20% NOM failure with blush per EAST multicenter study PMC10921525.
- **III**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Grade III = angioembolization candidate / highest AE rate (~38.9%) per WSES PMC6580626; embolization recommended grade III and above per StatPearls NBK441993.
- **IV**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · AAST greater-than-III ~77.1% operative rate per WSES PMC6580626; high-grade = surgery-predominant per StatPearls NBK441993.
- **V**: Kozar RA, Crandall M, Shanmuganathan K, et al.. Organ injury scaling 2018 update: spleen, liver, and kidney (AAST) (2018) — https://doi.org/10.1097/TA.0000000000002058 · Grade V predicts NOM failure/mortality and operative management per WSES PMC6580626 and StatPearls NBK441993; high-grade operative predominance (~77% for AAST greater-than-III).

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2018-01-01 | revised | AAST organ injury scales updated (2018). | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/aast-spleen · API JSON: https://radcommons.laudos.ai/api/v1/systems/aast-spleen · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# EU-TIRADS — European Thyroid Imaging Reporting and Data System

> European ultrasound risk stratification of thyroid nodules.

**Status:** current · **Organ:** Thyroid · **Issuing body:** European Thyroid Association · **Version:** 2017 · **Year:** 2017

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | EU-TIRADS 1, normal | Normal: no nodules present in the thyroid. | No fine-needle aspiration is indicated because category 1 means that no thyroid nodule is present to sample. | Not applicable (no nodule). | PMC5652895 (Russ et al., Eur Thyroid J 2017) Table 2 | ✓ |
| 2 | EU-TIRADS 2, benign | Benign: purely cystic nodule, or an entirely spongiform nodule. | FNA not indicated (except for therapeutic purposes). | Malignancy risk close to 0%. | PMC5652895 Benign Category section; Table 2 | ✓ |
| 3 | EU-TIRADS 3, low risk | Low risk: oval shape, smooth margins, isoechoic or hyperechoic, with no high-risk feature. | FNA if the nodule is larger than 20 mm. | Malignancy risk 2-4%. | PMC5652895 Low-Risk Category section; Table 2; Recommendation R3 | ✓ |
| 4 | EU-TIRADS 4, intermediate risk | Intermediate risk: oval shape, smooth margins, mildly hypoechoic, with no high-risk feature. | FNA if the nodule is larger than 15 mm. | Malignancy risk 6-17%. | PMC5652895 Intermediate-Risk Category section; Table 2; Recommendation R4 | ✓ |
| 5 | EU-TIRADS 5, high risk | High risk: nodule with at least one high-risk feature - non-oval (irregular) shape, irregular margins, microcalcifications, or marked hypoechogenicity. | FNA if the nodule is larger than 10 mm. | Malignancy risk 26-87%. | PMC5652895 High-Risk Category section; Table 2; Recommendation R5 | ✓ |

### Per-category citations
- **1**: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927 · PMC5652895 (Russ et al., Eur Thyroid J 2017) Table 2
- **2**: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927 · PMC5652895 Benign Category section; Table 2
- **3**: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927 · PMC5652895 Low-Risk Category section; Table 2; Recommendation R3
- **4**: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927 · PMC5652895 Intermediate-Risk Category section; Table 2; Recommendation R4
- **5**: Russ G, Bonnema SJ, Erdogan MF, et al.. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: EU-TIRADS (2017) — https://doi.org/10.1159/000478927 · PMC5652895 High-Risk Category section; Table 2; Recommendation R5

## Cross-references
- _shared boundary_ → [TI-RADS — ACR Thyroid Imaging Reporting and Data System](https://radcommons.laudos.ai/systems/ti-rads-2017.md) — Both stratify thyroid nodule malignancy risk on ultrasound. Categories, point logic, and size thresholds differ between the European and American systems.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2017-09-01 | published | EU-TIRADS published by the European Thyroid Association. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/eu-tirads · API JSON: https://radcommons.laudos.ai/api/v1/systems/eu-tirads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# K-TIRADS — Korean Thyroid Imaging Reporting and Data System

> Korean ultrasound risk stratification of thyroid nodules.

**Status:** current · **Organ:** Thyroid · **Issuing body:** Korean Society of Thyroid Radiology · **Version:** 2016 · **Year:** 2016

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: US
- Primary source: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370
- Last verified: 2026-07-24
- Last checked: 2026-07-24

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | K-TIRADS 1, no nodule | No nodule: the thyroid contains no discrete nodule on ultrasound. | Not applicable (no nodule to sample). | Malignancy risk is not applicable because no discrete thyroid nodule is present to stratify. | PMC4842857 (Shin et al., Korean J Radiol 2016;17(3):370) Table 2, category labelled 'no nodule' | ✓ |
| 2 | K-TIRADS 2, benign | Benign: spongiform nodule, partially cystic nodule with a comet-tail artifact, or a pure (simple) cyst. | Diagnostic FNA may be considered selectively when the nodule is 2 cm or larger; otherwise FNA is not indicated. | Estimated malignancy risk under about 3% (under roughly 1% for an isoechoic spongiform nodule). | PMC4842857 Table 2 (benign category) and Indications/Management text | ✓ |
| 3 | K-TIRADS 3, low suspicion | Low suspicion: a partially cystic or iso-/hyperechoic nodule that lacks all three suspicious ultrasound features (microcalcification, non-parallel/taller-than-wide orientation, spiculated or microlobulated margin). | FNA recommended when the nodule is 1.5 cm or larger. | Estimated malignancy risk approximately 3-15%. | PMC4842857 Table 2 (low-suspicion category) and Indications text | ✓ |
| 4 | K-TIRADS 4, intermediate suspicion | Intermediate suspicion: a solid hypoechoic nodule without any suspicious feature, or a partially cystic / iso- or hyperechoic nodule that has any one of the three suspicious ultrasound features. | FNA recommended when the nodule is 1 cm or larger. | Estimated malignancy risk approximately 15-50%. | PMC4842857 Table 2 (intermediate-suspicion category) and Indications text | ✓ |
| 5 | K-TIRADS 5, high suspicion | High suspicion: a solid hypoechoic nodule that has any of the three suspicious ultrasound features (microcalcification, non-parallel/taller-than-wide orientation, or spiculated/microlobulated margin). | FNA recommended when the nodule is 1 cm or larger; selective FNA may be considered above 0.5 cm. | Estimated malignancy risk above about 60%. | PMC4842857 Table 2 (high-suspicion category) and Indications text | ✓ |

### Per-category citations
- **1**: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370 · PMC4842857 (Shin et al., Korean J Radiol 2016;17(3):370) Table 2, category labelled 'no nodule'
- **2**: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370 · PMC4842857 Table 2 (benign category) and Indications/Management text
- **3**: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370 · PMC4842857 Table 2 (low-suspicion category) and Indications text
- **4**: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370 · PMC4842857 Table 2 (intermediate-suspicion category) and Indications text
- **5**: Shin JH, Baek JH, Chung J, et al.. Korean Thyroid Imaging Reporting and Data System (K-TIRADS) (2016) — https://doi.org/10.3348/kjr.2016.17.3.370 · PMC4842857 Table 2 (high-suspicion category) and Indications text

## Cross-references
- _shared boundary_ → [EU-TIRADS — European Thyroid Imaging Reporting and Data System](https://radcommons.laudos.ai/systems/eu-tirads.md) — Another regional thyroid ultrasound risk system; categories and FNA thresholds differ.
- _shared boundary_ → [TI-RADS — ACR Thyroid Imaging Reporting and Data System](https://radcommons.laudos.ai/systems/ti-rads-2017.md) — Korean alternative to ACR TI-RADS for thyroid nodule risk stratification, with different thresholds.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2016-05-01 | published | K-TIRADS published in the Korean Journal of Radiology. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/k-tirads · API JSON: https://radcommons.laudos.ai/api/v1/systems/k-tirads · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# TI-RADS — ACR Thyroid Imaging Reporting and Data System

> Point based ultrasound risk stratification of thyroid nodules across five feature categories, mapping a total score to a TR level and to biopsy or follow up by size.

**Status:** current · **Organ:** Thyroid · **Issuing body:** American College of Radiology · **Version:** 2017 · **Year:** 2017

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: score
- Modality: US
- Primary source: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
The score selects TR1-TR5; maximum nodule size then selects no action, scheduled ultrasound follow-up, or FNA. Previously biopsied and PET-avid nodules require the documented exceptions.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| TR1 | Benign | Total of 0 points across the five ACR TI-RADS feature categories (composition, echogenicity, shape, margin, echogenic foci). | No FNA and no follow-up recommended at any size. | Benign category; partial NMD analysis cited in the paper reports cancer risk of no more than 2% for TR1 and TR2 nodules combined. | ACR TI-RADS points table / risk-stratification chart (0 Points = TR1, Benign; "No FNA" row); discussion section ("cancer risk levels of no more than 2% for TR1 and TR2 nodules") | ✓ |
| TR2 | Not suspicious | Total of 2 points after adding the selected composition, echogenicity, shape, margin, and all applicable echogenic-foci values. | No FNA and no follow-up recommended at any size. | Not Suspicious category; partial NMD analysis cited in the paper reports cancer risk of no more than 2% for TR1 and TR2 nodules combined. | ACR TI-RADS points table / chart (2 Points = TR2, Not Suspicious; "No FNA" row); discussion section ("no more than 2% for TR1 and TR2 nodules") | ✓ |
| TR3 | Mildly suspicious | Total of 3 points after adding the selected composition, echogenicity, shape, margin, and all applicable echogenic-foci values. | FNA when maximum diameter is 2.5 cm or larger. For nodules 1.5-2.4 cm, follow-up ultrasound at 1, 3, and 5 years. No FNA or routine follow-up below 1.5 cm. | Mildly Suspicious category; partial NMD analysis cited in the paper reports cancer risk of approximately 5% for TR3 nodules. | ACR TI-RADS Atlas/assessment chart (3 points = TR3; FNA >=2.5 cm; follow >=1.5 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (follow-up at years 1, 3, and 5); white-paper discussion (approximately 5% risk) | ✓ |
| TR4 | Moderately suspicious | Total of 4-6 points after adding the selected composition, echogenicity, shape, margin, and all applicable echogenic-foci values. | FNA when maximum diameter is 1.5 cm or larger. For nodules 1.0-1.4 cm, follow-up ultrasound at 1, 2, 3, and 5 years. No FNA or routine follow-up below 1.0 cm. | Moderately Suspicious category; partial NMD analysis cited in the paper reports cancer risk of approximately 5% to 20% for TR4 nodules. | ACR TI-RADS Atlas/assessment chart (4-6 points = TR4; FNA >=1.5 cm; follow >=1.0 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (follow-up at years 1, 2, 3, and 5); white-paper discussion (approximately 5%-20% risk) | ✓ |
| TR5 | Highly suspicious | Total of 7 points or more after adding the selected composition, echogenicity, shape, margin, and all applicable echogenic-foci values. | FNA when maximum diameter is 1.0 cm or larger. For nodules 0.5-0.9 cm, follow-up ultrasound every year for 5 years. No FNA or routine follow-up below 0.5 cm. | Highly Suspicious category; partial NMD analysis cited in the paper reports cancer risk of at least 20% for TR5 nodules. | ACR TI-RADS Atlas/assessment chart (>=7 points = TR5; FNA >=1.0 cm; follow >=0.5 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (annual follow-up for 5 years); white-paper discussion (at least 20% risk) | ✓ |

### Per-category citations
- **TR1**: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046 · ACR TI-RADS points table / risk-stratification chart (0 Points = TR1, Benign; "No FNA" row); discussion section ("cancer risk levels of no more than 2% for TR1 and TR2 nodules")
- **TR2**: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046 · ACR TI-RADS points table / chart (2 Points = TR2, Not Suspicious; "No FNA" row); discussion section ("no more than 2% for TR1 and TR2 nodules")
- **TR3**: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046 · ACR TI-RADS Atlas/assessment chart (3 points = TR3; FNA >=2.5 cm; follow >=1.5 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (follow-up at years 1, 3, and 5); white-paper discussion (approximately 5% risk)
- **TR4**: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046 · ACR TI-RADS Atlas/assessment chart (4-6 points = TR4; FNA >=1.5 cm; follow >=1.0 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (follow-up at years 1, 2, 3, and 5); white-paper discussion (approximately 5%-20% risk)
- **TR5**: Tessler FN, Middleton WD, Grant EG, et al.. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee (2017) — https://doi.org/10.1016/j.jacr.2017.01.046 · ACR TI-RADS Atlas/assessment chart (>=7 points = TR5; FNA >=1.0 cm; follow >=0.5 cm); ACR Diagnostic Ultrasound Reporting Template, recommendation schedule (annual follow-up for 5 years); white-paper discussion (at least 20% risk)

## Cross-references
- _shared boundary_ → [BI-RADS — Breast Imaging Reporting and Data System, 5th edition](https://radcommons.laudos.ai/systems/bi-rads-2013.md) — Shares the ACR Reporting and Data System framework that BI-RADS established.
- _shared boundary_ → [EU-TIRADS — European Thyroid Imaging Reporting and Data System](https://radcommons.laudos.ai/systems/eu-tirads.md) — European alternative to ACR TI-RADS for thyroid nodule risk stratification, with different thresholds.

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-23 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-21 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-20 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-19 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-18 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-17 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-16 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-15 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-06-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2017-05-01 | published | ACR TI-RADS white paper published in JACR. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/ti-rads-2017 · API JSON: https://radcommons.laudos.ai/api/v1/systems/ti-rads-2017 · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# CEAP 2020 — CEAP 2020 classification of chronic venous disorders

> Per-limb Clinical-Etiologic-Anatomic-Pathophysiologic description of lower-extremity chronic venous disorders; the C axis is descriptive and is not a linear severity score.

**Status:** current · **Organ:** Vascular · **Issuing body:** American Venous Forum · **Version:** 2020 · **Year:** 2020

> ⚠️ A newer version may exist (under review).

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Clinical, US
- Primary source: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075
- Last verified: 2026-07-24
- Last checked: 2026-08-12

## Decision logic
Classify each limb independently. Keep the complete CEAP tuple when the evidence supports it; never turn the ordered C labels into a numeric severity score or infer E/A/P from appearance alone.

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| C0 | C0, no visible or palpable signs | No visible or palpable signs of venous disease in the classified lower extremity. C0 may still be suffixed s when symptoms attributable to venous disease are present or a when they are absent. | Do not equate C0 with normal venous hemodynamics. If the limb is symptomatic, complete the separate E, A and P assessment as clinically indicated; the C0 label itself supplies no treatment recommendation. | C0 is a descriptive examination finding, not a zero-risk category. It does not quantify future progression or exclude reflux, obstruction, or another venous cause of symptoms. | Lurie et al. 2020 CEAP update, DOI 10.1016/j.jvsv.2019.12.075, Table III (C0) and Clinical working-group discussion item 1 (C0s can have reflux/obstruction or no identified venous pathology). | ✓ |
| C1 | C1, telangiectasias or reticular veins | Telangiectasias or reticular veins in the classified limb. The 2020 task force retained them together as C1 rather than creating separate C1 subclasses. | Use C1 as a clinical descriptor and add symptom status plus E/A/P findings when known. Do not infer a target vein, reflux, obstruction, or need for intervention from C1 alone. | C1 carries no calibrated probability of progression, ulceration, or treatment benefit. The C ordering is not a linear severity or natural-history scale. | Lurie et al. 2020, Table III (C1) and Other Proposed Revisions (separate telangiectasia and reticular-vein subclasses were considered but not adopted). | ✓ |
| C2 | C2, varicose veins | Varicose veins in the classified limb without using the recurrence modifier. Vein diameter is not part of the 2020 CEAP C category, and origin or responsible venous segment must be described through E/A/P rather than inferred from C2. | Record s or a and complete etiology, anatomy and pathophysiology before management decisions. C2 does not identify which vein should be treated and is not itself an indication for a procedure. | C2 describes current varicose veins but supplies no patient-specific probability of progression, recurrence, thrombosis, ulceration, or response to treatment. | Lurie et al. 2020, Table III (C2), Clinical working-group discussion items 2-3 (origin and diameter are outside C), and conclusion that CEAP is descriptive rather than a severity/outcome measure. | ✓ |
| C2r | C2r, recurrent varicose veins | Recurrent varicose veins after prior treatment. The 2020 recurrence definition includes true recurrence, residual veins, and new varicose veins arising from disease progression after treatment. | Preserve the r modifier and document the prior intervention, distribution, etiology, anatomy, and reflux or obstruction. Recurrence can alter evaluation and strategy, but C2r alone does not select another procedure. | C2r distinguishes a potentially different natural history from untreated C2, but CEAP provides no numeric probability of further recurrence, complication, or treatment success. | Lurie et al. 2020, Table III (C2r) and Clinical revision subsection 'Subscript for C2 and C6 classes recurrent (r) disease' (scope includes true recurrence, residual veins, and progression after prior treatment). | ✓ |
| C3 | C3, edema | Edema attributable to chronic venous disease in the classified limb. C3 does not grade the extent, regional distribution, firmness, or phlebolymphedema component. | Document laterality, symptom status, distribution, and the separate E/A/P findings; evaluate competing causes of edema rather than assigning venous etiology from swelling alone. CEAP C3 does not prescribe treatment. | C3 is a broad descriptive class and has no per-limb event probability. It must not be used alone to predict ulceration, response, or need for intervention. | Lurie et al. 2020, Table III (C3) and Clinical working-group discussion item 4 (C3 does not encode degree, distribution, induration, or phlebolymphedema). | ✓ |
| C4a | C4a, pigmentation or eczema | Pigmentation or eczema attributable to chronic venous disease in the classified limb. Report coexisting C4b or C4c findings separately in advanced CEAP. | Treat C4a as a skin-manifestation descriptor and complete the venous E/A/P assessment. The label does not identify a responsible segment or mandate a particular intervention. | C4a denotes skin change associated with chronic venous disease but is not a calibrated ulcer-risk or outcome score and does not imply inevitable progression. | Lurie et al. 2020, Table III (C4a) and Clinical revision text retaining pigmentation or eczema as C4a. | ✓ |
| C4b | C4b, lipodermatosclerosis or atrophie blanche | Lipodermatosclerosis or atrophie blanche attributable to chronic venous disease in the classified limb. These findings remain grouped as C4b in the 2020 revision. | Document the specific skin finding, s or a status, and complete E/A/P characterization. C4b alone does not determine anatomy, pathophysiology, urgency, or treatment choice. | C4b represents advanced skin and subcutaneous-tissue change, but CEAP supplies no individual ulcer probability or treatment-outcome estimate for this class. | Lurie et al. 2020, Table III (C4b) and Clinical revision text retaining lipodermatosclerosis or atrophie blanche as C4b. | ✓ |
| C4c | C4c, corona phlebectatica | Corona phlebectatica: a fan-shaped pattern of numerous small intradermal veins on the medial or lateral ankle and foot, also called malleolar or ankle flare. It is a distinct C4 subclass in CEAP 2020 rather than C1. | Report C4c explicitly, retain any other C manifestations in advanced CEAP, and complete E/A/P characterization. Its presence justifies accurate venous assessment but does not by itself select treatment. | The task force placed corona phlebectatica in C4 because it is associated with advanced venous disease and ulcer development; this remains a population association, not an individual numeric forecast. | Lurie et al. 2020, Table III (C4c) and Clinical revision subsection 'Addition of corona phlebectatica to the C4 class' (definition, rationale, and association with ulcer development). | ✓ |
| C5 | C5, healed venous ulcer | Healed venous ulcer in the classified limb, with no currently active venous ulcer. The 2020 C axis has no C5r code; preserve relevant ulcer history separately. | Document ulcer site and history, symptom status, and full E/A/P findings when available. C5 describes the current healed state and does not determine prevention, surveillance, or intervention by itself. | Prior ulceration is clinically important, but CEAP C5 does not provide a calibrated probability of recurrence or benefit from a specific treatment. | Lurie et al. 2020, Table III (C5 healed) and Table III recurrence structure, in which r is defined only for C2 and C6. | ✓ |
| C6 | C6, active venous ulcer | Active venous ulcer in the classified limb without the recurrence modifier. If an active ulcer is known to have recurred after prior healing or treatment, use C6r instead. | Report the active ulcer and complete wound, clinical, etiologic, anatomic, and pathophysiologic assessment. C6 communicates active ulceration but does not replace wound evaluation or prescribe a venous intervention. | C6 identifies active ulcer disease but does not quantify healing time, recurrence, infection, limb risk, or treatment response for an individual patient. | Lurie et al. 2020, Table III (C6 active venous ulcer) and recurrence subsection distinguishing C6r. | ✓ |
| C6r | C6r, recurrent active venous ulcer | Recurrent active venous ulcer in the classified limb. Apply r only when recurrence is established; an active ulcer with unknown prior healing or treatment history should not be upgraded automatically to C6r. | Preserve recurrence history and complete the wound plus E/A/P description, including the veins associated with reflux or obstruction. C6r can affect clinical strategy but does not select treatment on its own. | C6r distinguishes recurrent from first-recorded active ulceration and may reflect a different natural history, but it is not a calibrated recurrence, healing, or complication score. | Lurie et al. 2020, Table III (C6r) and Clinical revision subsection 'Subscript for C2 and C6 classes recurrent (r) disease.' | ✓ |

### Per-category citations
- **C0**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020 CEAP update, DOI 10.1016/j.jvsv.2019.12.075, Table III (C0) and Clinical working-group discussion item 1 (C0s can have reflux/obstruction or no identified venous pathology).
- **C1**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C1) and Other Proposed Revisions (separate telangiectasia and reticular-vein subclasses were considered but not adopted).
- **C2**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C2), Clinical working-group discussion items 2-3 (origin and diameter are outside C), and conclusion that CEAP is descriptive rather than a severity/outcome measure.
- **C2r**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C2r) and Clinical revision subsection 'Subscript for C2 and C6 classes recurrent (r) disease' (scope includes true recurrence, residual veins, and progression after prior treatment).
- **C3**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C3) and Clinical working-group discussion item 4 (C3 does not encode degree, distribution, induration, or phlebolymphedema).
- **C4a**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C4a) and Clinical revision text retaining pigmentation or eczema as C4a.
- **C4b**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C4b) and Clinical revision text retaining lipodermatosclerosis or atrophie blanche as C4b.
- **C4c**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C4c) and Clinical revision subsection 'Addition of corona phlebectatica to the C4 class' (definition, rationale, and association with ulcer development).
- **C5**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C5 healed) and Table III recurrence structure, in which r is defined only for C2 and C6.
- **C6**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C6 active venous ulcer) and recurrence subsection distinguishing C6r.
- **C6r**: Lurie F, Passman M, Meisner M, et al.. The 2020 update of the CEAP classification system and reporting standards (2020) — https://doi.org/10.1016/j.jvsv.2019.12.075 · Lurie et al. 2020, Table III (C6r) and Clinical revision subsection 'Subscript for C2 and C6 classes recurrent (r) disease.'

## Version history

| Date | Event | Detail | Status |
| --- | --- | --- | --- |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2020-01-01 | revised | CEAP classification 2020 update and reporting standards. | confirmed |


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/ceap-venous · API JSON: https://radcommons.laudos.ai/api/v1/systems/ceap-venous · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# DeBakey — DeBakey classification of aortic dissection

> Classifies aortic dissection by origin and extent.

**Status:** current · **Organ:** Vascular · **Issuing body:** Vascular surgery consensus · **Version:** 1965 · **Year:** 1965

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: DeBakey ME, Henly WS, Cooley DA, et al.. Surgical management of dissecting aneurysms of the aorta (DeBakey classification) (1965) — https://www.ncbi.nlm.nih.gov/books/NBK441963/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I | Dissection originating in the ascending aorta and propagating distally through the aortic arch into the descending aorta (and often beyond) — i.e. it involves all three thoracic segments: ascending, arch and descending. Corresponds to Stanford type A. | Surgical emergency: open repair with excision of the intimal tear and ascending-aortic (and as needed arch) replacement using a synthetic graft. Medical management alone is inadequate because of the ascending-aorta involvement. | High-risk because of ascending-aortic involvement; in-hospital mortality for type A dissections is about 15-30%, with risk of tamponade, aortic rupture, coronary or cerebral malperfusion and aortic regurgitation. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 1, ascending+arch+descending; = Stanford A) and Treatment/Prognosis (surgical emergency, graft replacement; type A in-hospital mortality 15-30%). | ✓ |
| II | Type II | Dissection originating in and confined to the ascending aorta, not extending into the arch or descending aorta. Corresponds to Stanford type A. | Surgical emergency, same approach as type 1: excision of the intimal tear and ascending-aortic replacement with a synthetic graft. Ascending involvement mandates operative repair rather than medical therapy alone. | Type A physiology with high early mortality (about 15-30% in-hospital); principal threats are aortic rupture, pericardial tamponade, aortic regurgitation and proximal malperfusion. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 2, limited to ascending aorta; = Stanford A) and Treatment/Prognosis (surgical emergency; type A in-hospital mortality 15-30%). | ✓ |
| IIIa | Type IIIa | Dissection beginning in the descending aorta (distal to the left subclavian artery) and extending distally but remaining above the diaphragm, confined to the thoracic descending aorta. Corresponds to Stanford type B. | Uncomplicated cases: medical therapy first-line, with aggressive blood-pressure and heart-rate control (anti-impulse therapy). Complicated cases (malperfusion, rupture, refractory pain/hypertension): TEVAR stent-graft to seal the entry tear. | Lower early mortality than type A; in-hospital mortality for medically managed type B dissections is about 10-15%. Risk rises with complications such as malperfusion or rupture. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 3a, descending, above diaphragm; = Stanford B) and Treatment/Prognosis (uncomplicated -> medical BP/HR control, complicated -> TEVAR; medically managed type B in-hospital mortality 10-15%). | ✓ |
| IIIb | Type IIIb | Dissection beginning in the descending aorta (distal to the left subclavian artery) and extending below the diaphragm into the abdominal aorta. Corresponds to Stanford type B. | As for type 3a: medical anti-impulse therapy (blood-pressure and heart-rate control) for uncomplicated disease; TEVAR (or open/branched repair) when complicated by malperfusion, rupture or refractory symptoms. Abdominal extension can complicate stent-graft coverage. | Stanford type B prognosis with about 10-15% in-hospital mortality when medically managed; abdominal/visceral extension adds risk of renal or mesenteric malperfusion. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 3b, descending, below diaphragm into abdominal aorta; = Stanford B) and Treatment/Prognosis (medical vs TEVAR by complication; type B in-hospital mortality 10-15%). | ✓ |

### Per-category citations
- **I**: DeBakey ME, Henly WS, Cooley DA, et al.. Surgical management of dissecting aneurysms of the aorta (DeBakey classification) (1965) — https://www.ncbi.nlm.nih.gov/books/NBK441963/ · StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 1, ascending+arch+descending; = Stanford A) and Treatment/Prognosis (surgical emergency, graft replacement; type A in-hospital mortality 15-30%).
- **II**: DeBakey ME, Henly WS, Cooley DA, et al.. Surgical management of dissecting aneurysms of the aorta (DeBakey classification) (1965) — https://www.ncbi.nlm.nih.gov/books/NBK441963/ · StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 2, limited to ascending aorta; = Stanford A) and Treatment/Prognosis (surgical emergency; type A in-hospital mortality 15-30%).
- **IIIa**: DeBakey ME, Henly WS, Cooley DA, et al.. Surgical management of dissecting aneurysms of the aorta (DeBakey classification) (1965) — https://www.ncbi.nlm.nih.gov/books/NBK441963/ · StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 3a, descending, above diaphragm; = Stanford B) and Treatment/Prognosis (uncomplicated -> medical BP/HR control, complicated -> TEVAR; medically managed type B in-hospital mortality 10-15%).
- **IIIb**: DeBakey ME, Henly WS, Cooley DA, et al.. Surgical management of dissecting aneurysms of the aorta (DeBakey classification) (1965) — https://www.ncbi.nlm.nih.gov/books/NBK441963/ · StatPearls 'Aortic Dissection' (NBK441963), Introduction (DeBakey Type 3b, descending, below diaphragm into abdominal aorta; = Stanford B) and Treatment/Prognosis (medical vs TEVAR by complication; type B in-hospital mortality 10-15%).

## Cross-references
- _shared boundary_ → [Stanford — Stanford classification of aortic dissection](https://radcommons.laudos.ai/systems/stanford-dissection.md) — DeBakey maps onto the simpler Stanford A/B division.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/debakey-dissection · API JSON: https://radcommons.laudos.ai/api/v1/systems/debakey-dissection · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Endoleak — Endoleak classification after EVAR

> Classifies persistent aneurysm-sac perfusion after endovascular aneurysm repair by source.

**Status:** current · **Organ:** Vascular · **Issuing body:** Vascular surgery consensus · **Version:** current · **Year:** 2023

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, US, Angiography
- Primary source: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Type I, attachment-site leak | Inadequate seal at a graft attachment site lets blood track alongside the graft into the aneurysm sac. Subtype Ia is a proximal attachment-site leak; subtype Ib is a distal attachment-site leak. | Generally prompt intervention. Type Ia: balloon molding, a proximal cuff or stent, chimney or fenestrated EVAR, anchors, or embolization. Type Ib: distal graft extension. Open conversion if endovascular repair fails. | High rupture risk from continued sac pressurization and expansion. | PMC10312356 (Yanamaladoddi et al., Cureus 2023), 'Type I Endoleaks'; corroborated by StatPearls NBK554573 'Abdominal Aortic Repair', Complications. | ✓ |
| II | Type II, branch-vessel backflow | Retrograde (collateral) backflow into the aneurysm sac from aortic side branches, chiefly the lumbar arteries and the inferior mesenteric artery; the most common type overall. | Often observed; treated when the sac enlarges (about 5 mm or more over roughly 6 months) by transarterial, translumbar/direct-sac, or transcaval embolization, or surgical feeder ligation as an alternative. | Relatively benign; many resolve within about 6 months, but roughly 55% show sac enlargement within 3 years if persistent beyond 6 months. | PMC10312356, 'Type II Endoleaks'; corroborated by StatPearls NBK554573, Complications. | ✓ |
| III | Type III, graft defect or component separation | Mechanical graft failure perfusing the sac. Subtype IIIa is separation or disconnection between graft components (junctional); subtype IIIb is a fabric defect, tear, or hole. | Prompt intervention: endovascular relining with additional graft component(s) bridging or overlining the defect; open conversion if needed. | High rupture risk, comparable to type I. | PMC10312356, 'Type III Endoleaks'; corroborated by StatPearls NBK554573, Complications. | ✓ |
| IV | Type IV, graft porosity | Blood seeps through the inherent porosity of the graft fabric, with no discrete defect; usually seen early after implantation. | Usually transient and self-limiting; observation, rarely requiring intervention with modern devices (treatment generally not recommended). | Low-flow leak with minimal rupture risk; typically resolves once coagulation normalizes. | PMC10312356, 'Type IV Endoleaks'; risk and 'treatment not recommended' per Society for Vascular Surgery patient guideline (vascular.org 'Endoleaks (Type I-V)') and SVS clinical practice guidelines (J Vasc Surg endoleak management). | ✓ |
| V | Type V, endotension | Continued aneurysm-sac enlargement after EVAR with no demonstrable endoleak; a diagnosis of exclusion, also called endotension. | Surveillance, with intervention (graft relining or open conversion) suggested for ongoing sac expansion even without a visible endoleak. | Low risk in the short term, but continued sac enlargement confers a long-term aneurysm-rupture risk and usually warrants repair. | PMC10312356, 'Type V Endoleaks'; risk and management per Society for Vascular Surgery patient guideline (vascular.org 'Endoleaks (Type I-V)') and SVS clinical practice guidelines (J Vasc Surg endoleak management, grade 2C). | ✓ |

### Per-category citations
- **I**: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/ · PMC10312356 (Yanamaladoddi et al., Cureus 2023), 'Type I Endoleaks'; corroborated by StatPearls NBK554573 'Abdominal Aortic Repair', Complications.
- **II**: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/ · PMC10312356, 'Type II Endoleaks'; corroborated by StatPearls NBK554573, Complications.
- **III**: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/ · PMC10312356, 'Type III Endoleaks'; corroborated by StatPearls NBK554573, Complications.
- **IV**: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/ · PMC10312356, 'Type IV Endoleaks'; risk and 'treatment not recommended' per Society for Vascular Surgery patient guideline (vascular.org 'Endoleaks (Type I-V)') and SVS clinical practice guidelines (J Vasc Surg endoleak management).
- **V**: Yanamaladoddi VR, Sarvepalli SS, Vemula SL, et al.. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10312356/ · PMC10312356, 'Type V Endoleaks'; risk and management per Society for Vascular Surgery patient guideline (vascular.org 'Endoleaks (Type I-V)') and SVS clinical practice guidelines (J Vasc Surg endoleak management, grade 2C).


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/endoleak · API JSON: https://radcommons.laudos.ai/api/v1/systems/endoleak · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Fontaine — Fontaine classification of peripheral arterial disease

> Stages chronic limb ischemia by symptoms.

**Status:** current · **Organ:** Vascular · **Issuing body:** Vascular consensus · **Version:** 1954 · **Year:** 1954

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Angiography
- Primary source: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| I | Stage I, asymptomatic | Asymptomatic stage — peripheral arterial disease is present but the patient has no symptoms. | Cardiovascular risk-factor management: smoking cessation, statin and antiplatelet therapy, and control of diabetes/hypertension; no revascularization for the asymptomatic limb itself. | Up to ~50% of people with PAD are asymptomatic; even without limb symptoms, PAD marks elevated cardiovascular risk (stroke and myocardial infarction). | Wikipedia 'Peripheral artery disease', Classification section (Fontaine stage I 'asymptomatic') and Treatment/Prognosis sections (risk-factor management; ~50% asymptomatic; elevated stroke/MI risk). | ✓ |
| IIa | Stage IIa, mild claudication | Mild intermittent claudication — claudication pain that comes on after walking more than 200 metres. | Smoking cessation and supervised exercise therapy (treadmill walking ~30-60 min, at least 3x/week) plus risk-factor control; first-line for claudication, with revascularization usually reserved for lifestyle-limiting or refractory symptoms. | Claudication is relatively benign for the limb — over ~5 years only ~7% undergo bypass, ~4% major amputation, ~16% worsen — but systemic risk is high (estimated ~30% 5-year mortality from cardiovascular events). | Wikipedia 'Peripheral artery disease', Classification section (Fontaine IIa, claudication >200 m) and Treatment/Prognosis sections (supervised exercise 30-60 min 3x/week; 7% bypass, 4% amputation, 16% worsening; ~30% 5-year mortality). | ✓ |
| IIb | Stage IIb, moderate to severe claudication | Moderate-to-severe intermittent claudication — claudication pain that comes on after walking less than 200 metres. | As for IIa — smoking cessation, supervised exercise therapy and risk-factor control are first-line; revascularization (endovascular or bypass) is considered for lifestyle-limiting or exercise-refractory short-distance claudication. | Still a claudication (non-limb-threatening) stage with limb-outcome and ~30% 5-year cardiovascular mortality figures shared with IIa, though shorter pain-free distance reflects more severe disease. | Wikipedia 'Peripheral artery disease', Classification section (Fontaine IIb, claudication <200 m) and Treatment/Prognosis sections (exercise therapy/smoking cessation first-line; claudication-cohort outcomes and ~30% 5-year mortality). | ✓ |
| III | Stage III, rest pain | Ischemic rest pain — pain in the limb at rest, without exertion. | Part of chronic limb-threatening (critical) ischemia: revascularization is appropriate (endovascular or surgical bypass, with bypass recommended where life expectancy exceeds ~2 years), alongside analgesia and risk-factor management. | Critical limb ischemia / limb-threat category — clear risk of limb loss if adequate perfusion is not re-established. | Wikipedia 'Peripheral artery disease', Classification section (Fontaine III 'rest pain') and Treatment sections on chronic limb-threatening/critical limb ischemia (revascularization, bypass if life expectancy >2 years; risk of limb loss). | ✓ |
| IV | Stage IV, ulceration or gangrene | Tissue loss — ulceration or gangrene of the affected limb. | Critical limb ischemia with tissue loss: urgent revascularization to salvage the limb plus wound care; amputation may be required when gangrene is established or revascularization fails. | Highest-risk stage for limb loss — established gangrene/tissue death and infection often necessitate amputation. | Wikipedia 'Peripheral artery disease', Classification section (Fontaine IV 'ulcers or gangrene') and Treatment sections (revascularization vs amputation; amputation when gangrene established). | ✓ |

### Per-category citations
- **I**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Fontaine stage I 'asymptomatic') and Treatment/Prognosis sections (risk-factor management; ~50% asymptomatic; elevated stroke/MI risk).
- **IIa**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Fontaine IIa, claudication >200 m) and Treatment/Prognosis sections (supervised exercise 30-60 min 3x/week; 7% bypass, 4% amputation, 16% worsening; ~30% 5-year mortality).
- **IIb**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Fontaine IIb, claudication <200 m) and Treatment/Prognosis sections (exercise therapy/smoking cessation first-line; claudication-cohort outcomes and ~30% 5-year mortality).
- **III**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Fontaine III 'rest pain') and Treatment sections on chronic limb-threatening/critical limb ischemia (revascularization, bypass if life expectancy >2 years; risk of limb loss).
- **IV**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Fontaine IV 'ulcers or gangrene') and Treatment sections (revascularization vs amputation; amputation when gangrene established).

## Cross-references
- _shared boundary_ → [Rutherford — Rutherford classification of peripheral arterial disease](https://radcommons.laudos.ai/systems/rutherford-pad.md) — Two staging systems for chronic limb ischemia.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/fontaine-pad · API JSON: https://radcommons.laudos.ai/api/v1/systems/fontaine-pad · Agent index: https://radcommons.laudos.ai/llms.txt

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# NASCET — NASCET carotid stenosis measurement

> Quantifies internal carotid artery stenosis severity.

**Status:** current · **Organ:** Vascular · **Issuing body:** NASCET investigators · **Version:** 1991 · **Year:** 1991

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI, US
- Primary source: North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis (NASCET) (1991) — https://doi.org/10.1056/NEJM199108153250701
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| <50% | Mild stenosis | Mild internal carotid artery stenosis by the NASCET method — a NASCET-derived diameter reduction of 0-49%. NASCET quantifies stenosis by comparing the narrowest residual luminal diameter at the stenosis to the diameter of the normal distal cervical internal carotid artery (ICA) well beyond the bulb, where the walls are parallel and unaffected by plaque: percent stenosis = (1 - [minimal residual luminal diameter / diameter of normal distal ICA]) x 100. In the trial this band gained no significant benefit from carotid endarterectomy. | In symptomatic patients this degree of stenosis was found to derive no significant benefit from carotid endarterectomy (medical/best-medical management). | Lowest stroke risk of the symptomatic bands; surgery did not significantly reduce ipsilateral stroke and in the lowest-stenosis (<30%) subgroup CEA tended to be harmful (pooled 5-year RR ~1.25 for stroke/operative death), so the risk-benefit favours medical therapy. | Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis': 'According to NASCET, luminal stenosis is classified as "mild" (0-49%), "moderate" (50-69%), and "severe" (70-99%).' NASCET formula/measurement points from same section and from Wikipedia 'Carotid artery stenosis' Diagnosis section. 'No significant benefit <50%' and 'surgery tended to be harmful in participants with less than 30% stenosis' (RR ~1.25) from the Cochrane/CEA synthesis PMC6481587/PMC8536099 and StatPearls 'Carotid Endarterectomy' (NBK470582), Indications section. | ✓ |
| 50-69% | Moderate stenosis | Moderate internal carotid artery stenosis by the NASCET method — a NASCET-derived diameter reduction of 50-69% (measured by the same residual-lumen-vs-normal-distal-ICA ratio described for the <50% band). | Symptomatic patients with 50% or more ipsilateral stenosis plus a history of ipsilateral stroke or TIA are, per practice guidelines derived from NASCET, candidates for carotid endarterectomy; benefit in the moderate (50-69%) group is smaller than in the severe group. | Moderate stroke risk with modest surgical benefit. In NASCET, the 5-year risk of ipsilateral stroke for symptomatic 50-69% stenosis was about 15.7% with CEA versus 22.2% with medical therapy (absolute risk reduction roughly 6.5 percentage points, a ~29% relative reduction; number-needed-to-treat about 15). In pooled trial data the moderate band gave only a small benefit (5-year RR ~0.84). Benefit is therefore real but smaller than in the severe band and sensitive to surgical risk. | Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis' ('moderate' = 50-69%). 5-year CEA vs medical ipsilateral-stroke risk (15.7% vs 22.2%; ARR ~6.5%; RRR ~29%; NNT ~15) from WikiJournalClub NASCET summary (open-access, citing NEJM 1998); pooled 5-year RR ~0.84 for moderate stenosis from the Cochrane/CEA synthesis PMC6481587; CEA candidacy for >=50% symptomatic stenosis from StatPearls 'Carotid Endarterectomy' (NBK470582), Indications. | ✓ |
| 70-99% | Severe stenosis | Severe internal carotid artery stenosis by the NASCET method — a NASCET-derived diameter reduction of 70-99% (the residual lumen is reduced to little more than a thread relative to the normal distal ICA). This is the high-grade stenotic-but-still-patent band, short of complete occlusion. | Symptomatic 70-99% stenosis showed the greatest benefit from carotid endarterectomy in NASCET, establishing the 70% threshold as a key indication for surgery in symptomatic patients; the severe arm of the trial was stopped early because the benefit was so pronounced. | Highest stroke risk and greatest surgical benefit of the symptomatic bands. In the pooled trial analysis, CEA roughly halved the 5-year ipsilateral-stroke risk for severe (70-99%) stenosis (RR ~0.47, approximately 10% surgical vs 23% medical). The benefit was large enough that the severe arm was terminated early and all such patients referred for CEA. | Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis' ('severe' = 70-99%). Pooled 5-year ipsilateral-stroke RR ~0.47 (~10% surgical vs ~23% medical) for >=70% stenosis from the Cochrane/CEA synthesis PMC6481587; early termination of the severe arm and CEA benefit from WikiJournalClub NASCET summary (open-access) and StatPearls NBK470582, Indications. | ✓ |
| occlusion | Near occlusion or occlusion | Complete (100%) occlusion of the internal carotid artery — there is no residual lumen, so a NASCET percent-stenosis ratio cannot be meaningfully computed (NASCET treated near-occlusion/occlusion as a distinct category rather than calculating a percentage). Distinct from the patent 70-99% severe band. | Carotid endarterectomy is generally not indicated for a completely (chronically) occluded ICA, since there is no lumen to reopen; management is medical/best-medical therapy. The separate 'near-occlusion' subgroup (a tight stenosis with a collapsed/threadlike distal ICA) showed little or no clear benefit from surgery in the NASCET analyses and is also typically managed medically. | Near-occlusion paradoxically carried a relatively low subsequent stroke risk on medical therapy in NASCET (lower than the 70-99% severe band), which is part of why surgical benefit was not demonstrated for it; complete occlusion is not amenable to revascularization. | Occlusion (100%) / near-occlusion handled as a distinct category beyond the calculable bands per ESCR consensus (PMC9889495), Table 1 categories 'Near-occlusion'/'Occlusion'. No-benefit/low-risk of near-occlusion and non-revascularization of complete occlusion from NASCET near-occlusion analyses as summarized in StatPearls NBK470582 and the NASCET/CEA syntheses (PMC8536099); near-occlusion percent-not-calculated point corroborated by Wikipedia 'Carotid artery stenosis'. | ✓ |

### Per-category citations
- **<50%**: North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis (NASCET) (1991) — https://doi.org/10.1056/NEJM199108153250701 · Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis': 'According to NASCET, luminal stenosis is classified as "mild" (0-49%), "moderate" (50-69%), and "severe" (70-99%).' NASCET formula/measurement points from same section and from Wikipedia 'Carotid artery stenosis' Diagnosis section. 'No significant benefit <50%' and 'surgery tended to be harmful in participants with less than 30% stenosis' (RR ~1.25) from the Cochrane/CEA synthesis PMC6481587/PMC8536099 and StatPearls 'Carotid Endarterectomy' (NBK470582), Indications section.
- **50-69%**: North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis (NASCET) (1991) — https://doi.org/10.1056/NEJM199108153250701 · Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis' ('moderate' = 50-69%). 5-year CEA vs medical ipsilateral-stroke risk (15.7% vs 22.2%; ARR ~6.5%; RRR ~29%; NNT ~15) from WikiJournalClub NASCET summary (open-access, citing NEJM 1998); pooled 5-year RR ~0.84 for moderate stenosis from the Cochrane/CEA synthesis PMC6481587; CEA candidacy for >=50% symptomatic stenosis from StatPearls 'Carotid Endarterectomy' (NBK470582), Indications.
- **70-99%**: North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis (NASCET) (1991) — https://doi.org/10.1056/NEJM199108153250701 · Severity band from ESCR consensus (PMC9889495), 'Quantifying the degree of stenosis' ('severe' = 70-99%). Pooled 5-year ipsilateral-stroke RR ~0.47 (~10% surgical vs ~23% medical) for >=70% stenosis from the Cochrane/CEA synthesis PMC6481587; early termination of the severe arm and CEA benefit from WikiJournalClub NASCET summary (open-access) and StatPearls NBK470582, Indications.
- **occlusion**: North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis (NASCET) (1991) — https://doi.org/10.1056/NEJM199108153250701 · Occlusion (100%) / near-occlusion handled as a distinct category beyond the calculable bands per ESCR consensus (PMC9889495), Table 1 categories 'Near-occlusion'/'Occlusion'. No-benefit/low-risk of near-occlusion and non-revascularization of complete occlusion from NASCET near-occlusion analyses as summarized in StatPearls NBK470582 and the NASCET/CEA syntheses (PMC8536099); near-occlusion percent-not-calculated point corroborated by Wikipedia 'Carotid artery stenosis'.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/nascet-carotid · API JSON: https://radcommons.laudos.ai/api/v1/systems/nascet-carotid · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Rutherford — Rutherford classification of peripheral arterial disease

> Categorizes chronic limb ischemia severity.

**Status:** current · **Organ:** Vascular · **Issuing body:** Vascular consensus · **Version:** 1997 · **Year:** 1997

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: Angiography
- Primary source: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Category 0, asymptomatic | Asymptomatic chronic lower-limb ischemia; no claudication, rest pain or tissue loss. Disease may be detectable only objectively (e.g. reduced ankle-brachial index) without functional symptoms. | Risk-factor modification only: smoking cessation, statin and antiplatelet therapy, control of diabetes/hypertension. No revascularization indicated for the asymptomatic state. | Benign limb prognosis; only about 1-3% of claudicants per year progress to critical limb-threatening ischemia, and asymptomatic disease progresses even more slowly. Cardiovascular (MI/stroke) risk drives overall mortality. | Wikipedia 'Peripheral artery disease', Classification section (Rutherford category 0, 'asymptomatic'); management and progression rate from StatPearls 'Peripheral Arterial Disease' (NBK430745), Treatment and Prognosis sections (lifestyle/medical first-line; '1% to 3% per year progress to critical limb ischemia'). | ✓ |
| 1 | Category 1, mild claudication | Mild intermittent claudication: reproducible ischemic muscle pain on exertion that does not markedly limit walking. Corresponds clinically to mild PAD (ankle-brachial index roughly 0.70-0.90). | First-line conservative therapy: supervised exercise/walking program, smoking cessation and pharmacologic risk-factor control (statin, antiplatelet); cilostazol may improve walking distance. | Stable claudication carries a low limb-loss risk; roughly 1-3% of claudicants per year progress to critical limb ischemia. Major risk is cardiovascular mortality, not amputation. | Wikipedia 'Peripheral artery disease', Classification section (category 1, 'mild claudication'); ABI band, conservative therapy and progression rate from StatPearls NBK430745 (mild PAD ABI 0.70-0.90; first-line lifestyle/exercise/pharmacologic; 1-3%/yr to CLI). | ✓ |
| 2 | Category 2, moderate claudication | Moderate intermittent claudication: exertional ischemic limb pain of intermediate severity, between categories 1 and 3. Corresponds clinically to moderate PAD (ankle-brachial index roughly 0.50-0.70). | Supervised exercise therapy and medical risk-factor optimization remain first-line; endovascular or surgical revascularization is reserved for lifestyle-limiting symptoms refractory to conservative measures. | Low annual risk of progression to limb-threatening ischemia (about 1-3% per year); prognosis dominated by concurrent coronary/cerebrovascular disease. | Wikipedia 'Peripheral artery disease', Classification section (category 2, 'moderate claudication'); moderate-PAD ABI band and management/progression from StatPearls NBK430745 (ABI 0.50-0.70; exercise first-line, revascularization for refractory cases). | ✓ |
| 3 | Category 3, severe claudication | Severe intermittent claudication: markedly walking-limiting exertional ischemic pain that does not yet occur at rest. Most severe claudication grade before the critical-ischemia categories. | Conservative therapy continues, but lifestyle-limiting severe claudication refractory to exercise/medical therapy is an indication for revascularization (endovascular angioplasty/stenting or bypass surgery). | Still primarily a quality-of-life rather than limb-threat problem; overall progression of claudication to critical limb ischemia remains roughly 1-3% per year. | Wikipedia 'Peripheral artery disease', Classification section (category 3, 'severe claudication'); revascularization-for-refractory-claudication and progression rate from StatPearls NBK430745 (endovascular/bypass for refractory disease). | ✓ |
| 4 | Category 4, rest pain | Ischemic rest pain: continuous pain at rest from inadequate perfusion, classically in the forefoot/toes, worse when supine and relieved by dependency. Marks the onset of chronic limb-threatening ischemia (ankle-brachial index typically under 0.50; low ankle/toe pressures). | Limb-threatening ischemia: urgent revascularization (endovascular or surgical bypass) to relieve pain and salvage the limb, with aggressive risk-factor and wound/foot care; medical therapy alone is insufficient. | Chronic limb-threatening ischemia carries a high amputation risk of roughly 25-40% at 1 year together with markedly elevated cardiovascular mortality. | Wikipedia 'Peripheral artery disease', Classification section (category 4, 'rest pain'); CLTI threshold, revascularization need and amputation risk from StatPearls NBK430745 (ABI <0.50 = severe PAD/CLTI; 'risk of amputation is about 25% to 40% at 1 year'). | ✓ |
| 5 | Category 5, minor tissue loss | Minor tissue loss: ischemic ulceration or focal gangrene limited to the digits/forefoot, not extending beyond a non-healing toe ulcer. A form of chronic limb-threatening ischemia. | Limb-threatening ischemia requiring prompt revascularization for wound healing and limb salvage, combined with local wound care/debridement, infection control and risk-factor optimization. | Limb-threatening ischemia with high 1-year amputation risk (about 25-40%) and high cardiovascular mortality; tissue loss further worsens limb prognosis versus rest pain alone. | Wikipedia 'Peripheral artery disease', Classification section (category 5, 'minor tissue loss; ischemic ulceration not exceeding ulcer of the digits'); CLTI management and 1-year amputation risk from StatPearls NBK430745. | ✓ |
| 6 | Category 6, major tissue loss | Major tissue loss: extensive ischemic ulceration or frank gangrene extending above the transmetatarsal level, beyond salvageable digits, often with non-viable foot tissue. The most advanced category of chronic limb-threatening ischemia. | Urgent revascularization for any salvageable tissue, but extensive necrosis often necessitates major (below- or above-knee) amputation; aggressive infection control and risk-factor management throughout. | Worst limb prognosis with the highest likelihood of major amputation (overall CLTI amputation risk about 25-40% at 1 year, greatest with extensive tissue loss) and very high cardiovascular mortality. | Wikipedia 'Peripheral artery disease', Classification section (category 6, 'major tissue loss; severe ischemic ulcers or frank gangrene'); CLTI management and amputation risk from StatPearls NBK430745. | ✓ |

### Per-category citations
- **0**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (Rutherford category 0, 'asymptomatic'); management and progression rate from StatPearls 'Peripheral Arterial Disease' (NBK430745), Treatment and Prognosis sections (lifestyle/medical first-line; '1% to 3% per year progress to critical limb ischemia').
- **1**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 1, 'mild claudication'); ABI band, conservative therapy and progression rate from StatPearls NBK430745 (mild PAD ABI 0.70-0.90; first-line lifestyle/exercise/pharmacologic; 1-3%/yr to CLI).
- **2**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 2, 'moderate claudication'); moderate-PAD ABI band and management/progression from StatPearls NBK430745 (ABI 0.50-0.70; exercise first-line, revascularization for refractory cases).
- **3**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 3, 'severe claudication'); revascularization-for-refractory-claudication and progression rate from StatPearls NBK430745 (endovascular/bypass for refractory disease).
- **4**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 4, 'rest pain'); CLTI threshold, revascularization need and amputation risk from StatPearls NBK430745 (ABI <0.50 = severe PAD/CLTI; 'risk of amputation is about 25% to 40% at 1 year').
- **5**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 5, 'minor tissue loss; ischemic ulceration not exceeding ulcer of the digits'); CLTI management and 1-year amputation risk from StatPearls NBK430745.
- **6**: Fontaine R; Rutherford RB. Classification of chronic limb ischemia (Fontaine and Rutherford) (1954) — https://en.wikipedia.org/wiki/Peripheral_artery_disease · Wikipedia 'Peripheral artery disease', Classification section (category 6, 'major tissue loss; severe ischemic ulcers or frank gangrene'); CLTI management and amputation risk from StatPearls NBK430745.

## Cross-references
- _shared boundary_ → [Fontaine — Fontaine classification of peripheral arterial disease](https://radcommons.laudos.ai/systems/fontaine-pad.md) — Finer-grained alternative to Fontaine staging.


---
> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

HTML page: https://radcommons.laudos.ai/systems/rutherford-pad · API JSON: https://radcommons.laudos.ai/api/v1/systems/rutherford-pad · Agent index: https://radcommons.laudos.ai/llms.txt

<hr/>

# Stanford — Stanford classification of aortic dissection

> Classifies aortic dissection by involvement of the ascending aorta.

**Status:** current · **Organ:** Vascular · **Issuing body:** Vascular surgery consensus · **Version:** 1970 · **Year:** 1970

## Provenance and currency
- Family: lexicon
- Logic type: flat
- Modality: CT, MRI
- Primary source: Daily PO, Trueblood HW, Stinson EB, et al.. Management of acute aortic dissections (Stanford classification) (1970) — https://en.wikipedia.org/wiki/Aortic_dissection
- Last verified: 2026-06-26
- Last checked: 2026-06-26

## Categories

| Code | Label | Criteria | Management | Risk | Locator | Verified |
| --- | --- | --- | --- | --- | --- | --- |
| A | Type A (ascending involved) | Any aortic dissection that involves the ascending aorta, irrespective of where the primary intimal entry tear is located. By definition these are dissections sitting proximal to the brachiocephalic (innominate) artery; the process may also extend into the arch and descending aorta, but ascending-aorta involvement is what defines type A. | Generally treated as a surgical emergency, with urgent open repair (excision of the intimal tear, graft replacement of the ascending aorta, with aortic valve repair/replacement as needed) the usual first-line approach. | High early mortality if untreated — rising roughly 1-2% per hour in the first 24-48 hours and approaching ~50% by the end of the first week. With surgery, reported in-hospital mortality is ~15-30%, with ~70-80% 5-year survival. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (Stanford Type A definition) and Prognosis/Treatment sections (untreated ~1-2%/hour early mortality, ~50% by 1 week; surgical in-hospital mortality ~15-30%; ~70-80% 5-year survival). Definition corroborated by Wikipedia 'Aortic dissection', Classification section. | ✓ |
| B | Type B (descending only) | Aortic dissection that does NOT involve the ascending aorta. The entry tear and dissection originate distal to the origin of the left subclavian artery and involve only the descending aorta (and beyond), with the ascending aorta spared. | Initial medical management for uncomplicated cases (anti-impulse therapy: blood-pressure and heart-rate control), with endovascular stent-grafting (TEVAR) or surgery reserved for complications such as malperfusion or rupture. | Uncomplicated type B with medical therapy has ~10-15% in-hospital mortality and ~75-85% 5-year survival; complicated type B (malperfusion or rupture) can exceed ~30-40% in-hospital mortality if not promptly treated. | StatPearls 'Aortic Dissection' (NBK441963), Introduction (Stanford Type B definition) and Prognosis/Treatment sections (uncomplicated medical mortality ~10-15%, ~75-85% 5-year survival; complicated ~30-40% mortality; TEVAR/surgery for complications). Definition and medical-vs-intervention contrast corroborated by Wikipedia 'Aortic dissection', Classification section. | ✓ |

### Per-category citations
- **A**: Daily PO, Trueblood HW, Stinson EB, et al.. Management of acute aortic dissections (Stanford classification) (1970) — https://en.wikipedia.org/wiki/Aortic_dissection · StatPearls 'Aortic Dissection' (NBK441963), Introduction (Stanford Type A definition) and Prognosis/Treatment sections (untreated ~1-2%/hour early mortality, ~50% by 1 week; surgical in-hospital mortality ~15-30%; ~70-80% 5-year survival). Definition corroborated by Wikipedia 'Aortic dissection', Classification section.
- **B**: Daily PO, Trueblood HW, Stinson EB, et al.. Management of acute aortic dissections (Stanford classification) (1970) — https://en.wikipedia.org/wiki/Aortic_dissection · StatPearls 'Aortic Dissection' (NBK441963), Introduction (Stanford Type B definition) and Prognosis/Treatment sections (uncomplicated medical mortality ~10-15%, ~75-85% 5-year survival; complicated ~30-40% mortality; TEVAR/surgery for complications). Definition and medical-vs-intervention contrast corroborated by Wikipedia 'Aortic dissection', Classification section.

## Cross-references
- _shared boundary_ → [DeBakey — DeBakey classification of aortic dissection](https://radcommons.laudos.ai/systems/debakey-dissection.md) — Two systems for aortic dissection: Stanford by ascending involvement, DeBakey by origin and extent.


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> Rewritten reference content. Check the current primary publication. Not a medical device and not a substitute for clinical judgment. The reporting radiologist remains the author and the responsible party.

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