How do I convince a radiologist to give an early computed tomography (CT) brain appointment to an elderly patient with recurrent falls to rule out multifocal cerebral infarct?

How to Obtain an Early CT Brain for an Elderly Patient with Recurrent Falls

For an elderly patient with recurrent falls, you should emphasize the high risk of stroke and request urgent CT imaging within 24 hours, citing the need to rule out multifocal infarcts that may be causing the falls and require immediate intervention.

Clinical Justification Strategy

When communicating with radiology, focus on these evidence-based points:

1. Emphasize Stroke Risk Factors:

   • Recurrent falls in elderly patients can be a manifestation of cerebrovascular disease, particularly multifocal infarcts 1
   • Falls may represent a neurological emergency requiring prompt evaluation 1
   • The Canadian Stroke Best Practice Recommendations support urgent imaging for patients with symptoms that could indicate stroke risk 1

2. Highlight Time-Sensitive Nature:

   • According to guidelines, patients with suspected TIA or stroke symptoms should receive brain imaging within 24 hours 1
   • Early detection of multifocal infarcts is critical for secondary stroke prevention 1
   • The risk of recurrent stroke is highest in the first days to weeks after initial symptoms 1

3. Document Specific Neurological Findings:

   • Note any focal neurological deficits, which significantly increase the likelihood of finding intracranial pathology (RR = 6.36) 2
   • Document any consciousness impairment, which is associated with higher risk of traumatic lesions (RR = 1.56) 2
   • Mention any history of prior head injury, which increases risk of findings (RR = 7.17) 2

Practical Approach

1. Make a Direct Request:

   • Call the radiology department directly rather than just submitting an electronic request
   • Ask to speak with the radiologist on duty or the neuroradiology specialist
   • Introduce yourself and explain the clinical urgency

2. Present the Case Effectively:

   • "I have an elderly patient with recurrent falls who needs urgent CT brain imaging to rule out multifocal infarcts"
   • Specify any of these high-risk features if present:
     • Unilateral weakness (face, arm, leg)
     • Speech disturbance
     • Sensory symptoms
     • Visual disturbances
     • Ataxia or balance problems
     • Recent deterioration in mobility

3. Reference Guidelines:

   • "The Canadian Stroke Best Practice Recommendations indicate that patients with these symptoms should receive brain imaging within 24 hours" 1
   • "The ACR Appropriateness Criteria support urgent CT imaging in this clinical scenario" 1

4. Propose a Comprehensive Imaging Plan:

   • Request CT brain without contrast as the initial study 1
   • Suggest CT angiography (CTA) from aortic arch to vertex if there's concern for vascular etiology 1
   • This approach aligns with guidelines that recommend complete vascular assessment 1

Common Pitfalls to Avoid

1. Don't focus solely on trauma:

   • While falls can cause traumatic brain injury, your concern is identifying underlying cerebrovascular disease causing the falls
   • The ACR guidelines note that CT is appropriate for evaluating both traumatic and non-traumatic causes of neurological symptoms 1

2. Don't accept long delays:

   • If offered a routine appointment weeks away, emphasize that guidelines recommend imaging within 24 hours for suspected cerebrovascular disease 1
   • Point out that early diagnosis can prevent further falls and potential injuries

3. Don't neglect to document your request:

   • Record your conversation with radiology in the patient's chart
   • Document the clinical reasoning for urgent imaging
   • Follow up with written documentation of your request

By following this approach and emphasizing the evidence-based need for urgent imaging, you'll increase your chances of securing an early CT brain appointment for your elderly patient with recurrent falls.