How to Read an MRI: Systematic Interpretation Guide for Clinicians

MRI interpretation requires a structured approach to avoid missing subtle pathology. While radiologists undergo years of training, understanding the framework helps referring clinicians correlate findings with clinical context.

Systematic MRI Review Checklist

1. Clinical Context: Review indication, history, prior imaging, labs. "Why was this ordered?"
2. Patient & Study Verification: Correct patient, date, body part, sequences acquired.
3. Image Quality Assessment: Motion artifact, wrap-around, fat suppression homogeneity, SNR, contrast timing.
4. Orientation & Localization: Identify planes (axial, sagittal, coronal, oblique). Use anatomical landmarks. Confirm laterality markers.
5. Sequence Analysis:
   • T1: Anatomy, fat (bright), hemorrhage (subacute bright), contrast enhancement.
   • T2: Fluid (bright), edema, inflammation, cystic lesions.
   • FLAIR: CSF suppressed; periventricular lesions, MS plaques, edema.
   • DWI/ADC: Acute ischemia (restricted diffusion), abscess, tumor cellularity.
   • GRE/SWI: Blood products, microbleeds, calcifications, vessels.
   • Post-Contrast T1: Breakdown of blood-brain barrier (tumors, infection, inflammation).
6. Anatomical Survey: Systematically evaluate each compartment (brain: ventricles, basal ganglia, cortex, brainstem, cerebellum, orbits; spine: vertebrae, discs, cord, canal, foramina).
7. Symmetry Comparison: Compare hemispheres / left-right sides for asymmetry.
8. Search Pattern: Use a consistent checklist (e.g., "ABCD": Air/Artifact, Brain/Bone, Cisterns/Cord, Dura/Diffusion).
9. Prior Comparison: Side-by-side with previous exams for interval change.
10. Measurements: Lesion size (3D), midline shift, ventricular indices, enhancement pattern.
11. Differential Diagnosis: Formulate ranked list based on imaging phenotype + clinical context.
12. Report Synthesis: Technique, Findings (pertinent +/−), Impression (diagnosis/ddx), Recommendations.

Key Principles

• Signal intensity is relative—always compare to adjacent normal tissue (CSF, fat, muscle, gray/white matter).
• Artifacts mimic pathology—recognize motion, flow, susceptibility, chemical shift, Gibbs ringing.
• Clinical correlation is mandatory; imaging findings ≠ diagnosis in isolation.

When in doubt, consult the radiologist. Collaborative interpretation optimizes patient care.