71 Female Ongoing confusion, confusion screen done negative CT Head Done: Nil Acute findings MRI Head to Rule Out, what to write
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This is a clinical documentation question — a 71-year-old female with ongoing confusion, negative confusion screen (e.g., bCAM/CAM), CT head showing no acute findings, and now the team wants to write an MRI brain request. Here is how to approach this clearly:
MRI Head Referral/Request Wording
Clinical scenario summary for the form:
71-year-old female presenting with ongoing confusion/altered mental status. Confusion screening (bCAM/CAM) negative. CT head: no acute intracranial pathology identified. MRI brain requested to further evaluate for underlying structural, vascular, or neurodegenerative cause of confusion.
What to Write in the MRI Request
Clinical Indication (choose the most applicable or combine):
71F with subacute/ongoing confusion, ?cause. CT head NAD. MRI brain requested to exclude:
- Early or established dementia (Alzheimer's, vascular, Lewy body, frontotemporal)
- Small vessel ischaemic disease / lacunar infarcts
- Posterior circulation or cortical infarction not visible on CT
- Leptomeningeal or parenchymal metastatic disease
- Autoimmune/limbic encephalitis
- Normal pressure hydrocephalus (gait disturbance, cognitive decline, urinary incontinence)
- Prion disease (CJD) if rapid progression
Suggested One-Line Request Phrases (pick one based on clinical context):
| Clinical Suspicion | Suggested Phrase |
|---|---|
| General/dementia workup | "MRI brain: ongoing confusion, CT NAD, ?neurodegenerative / vascular dementia" |
| Suspected vascular/stroke | "MRI brain with DWI: exclude posterior circulation infarct, small vessel disease" |
| Encephalitis/autoimmune | "MRI brain: ?limbic encephalitis / autoimmune encephalopathy — ongoing confusion, CT NAD" |
| NPH | "MRI brain: ?normal pressure hydrocephalus — confusion, gait disturbance" |
| CJD / rapid decline | "MRI brain with DWI + FLAIR: ?prion disease — rapidly progressive confusion" |
Key Sequences to Mention (if your department requests sequences)
- T1, T2, FLAIR — white matter disease, atrophy, lesions
- DWI/ADC — acute/subacute infarction (especially posterior fossa, which CT misses)
- T1 post-contrast — if malignancy, encephalitis, or meningeal disease suspected
- SWI/GRE — microhaemorrhages, CAA
- MR spectroscopy / perfusion — if prion disease or tumour queried
Clinical Rationale (for documentation/notes)
CT head has low sensitivity for:
- Early ischaemic stroke (especially posterior fossa/brainstem)
- Small vessel ischaemic disease
- Cortical/limbic encephalitis
- Early neurodegenerative changes
- Leptomeningeal carcinomatosis
MRI is the preferred modality in elderly patients with unexplained or ongoing confusion after a negative CT — Rosen's Emergency Medicine notes that focal cortical dysfunction and many structural causes of confusion are not visible on CT alone.
Bottom line wording for the request box:
"71F, ongoing confusion, negative delirium screen, CT head NAD. MRI brain requested to exclude vascular, neurodegenerative, or structural aetiology. Please include DWI, FLAIR, and T1 ± contrast."
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