MRI Brain Seizure/Epilepsy — Dictation, Appropriateness, and Dose for Residents
1. The Seizure Protocol Read: Finding the Needle in the Haystack
It’s 3 PM on a Tuesday. An outpatient MRI brain seizure protocol lands on your list. 24-year-old, new-onset focal seizures, already failing first-line meds. The neurologist isn’t just asking for a read; they’re hunting for a surgical target. Your attending expects you to not only rule out a mass but to meticulously evaluate for the subtle signs of mesial temporal sclerosis or a tiny focus of cortical dysplasia. This isn’t a “no acute intracranial process” read. This is a search.
When I was a PGY-2 on neuro, just eyeballing hippocampal volumes side-by-side felt like a shot in the dark. The difference between a normal variant and early atrophy can be incredibly subtle. Having a systematic approach, knowing exactly what sequences to lean on, and structuring your report to answer the clinical question is what separates a good read from a great one. It’s also what gets you home on time. For more tools to get you through call, check out the residents and fellows resource hub we built.
2. What an MRI Brain for Seizure and Epilepsy Covers and What Attendings Look For
The primary goal of a dedicated epilepsy protocol MRI is to identify a structural correlate for a patient’s seizures. While many scans will be negative, a positive finding can be life-changing, opening the door to targeted medical therapy or curative surgery. Your report needs to be a comprehensive survey for these potential causes.
Attendings expect a systematic evaluation that explicitly addresses the most common epileptogenic substrates. Your report should clearly comment on:
- Mesial Temporal Sclerosis (MTS): The most common cause of refractory temporal lobe epilepsy. Look for hippocampal atrophy and T2/FLAIR hyperintensity.
- Malformations of Cortical Development: This includes focal cortical dysplasia (FCD), polymicrogyria, lissencephaly, and schizencephaly.
- Epilepsy-Associated Tumors: Primarily low-grade tumors like dysembryoplastic neuroepithelial tumors (DNETs) and gangliogliomas.
- Vascular Malformations: Cavernomas and arteriovenous malformations (AVMs) are key culprits.
- Sequelae of Prior Injury: Look for gliosis and encephalomalacia from previous trauma, stroke, or infection.
- Phakomatoses: Signs of tuberous sclerosis (cortical tubers, subependymal nodules) or Sturge-Weber syndrome.
3. Radiology Report Template for MRI Brain Seizure/Epilepsy
Use this template as a starting point for your macros. The key is a systematic search pattern so you don’t miss subtle findings.
Technique
Multiplanar, multisequence MRI of the brain was performed using a dedicated seizure protocol. This included high-resolution coronal T2 and FLAIR/STIR sequences angled perpendicular to the long axis of the hippocampi. Post-contrast T1-weighted images were [acquired/not acquired].
Sequences: [e.g., Sagittal 3D T1 MPRAGE, Axial T2, Axial FLAIR, Axial DWI/ADC, Coronal high-resolution T2, Coronal STIR, Axial SWI]
Findings
Hippocampi: Symmetrically sized and structured. Normal T2 and FLAIR signal. No evidence of volume loss, abnormal signal, or loss of internal architecture to suggest mesial temporal sclerosis.
Cortical Development: No evidence of cortical thickening, blurring of the gray-white matter junction, or abnormal gyral patterns to suggest a malformation of cortical development. No transmantle sign.
Ventricles and Extra-Axial Spaces: Normal in size and configuration.
Other Brain Parenchyma: No mass, mass effect, or midline shift. No evidence of hemorrhage, infarct, or abnormal signal intensity. Specifically, no “popcorn” lesion on SWI to suggest a cavernoma.
Post-Contrast Imaging (if performed): No abnormal parenchymal, leptomeningeal, or dural enhancement.
Sinuses and Mastoids: Clear.
Orbits and Skull Base: Unremarkable.
Impression
1. No structural correlate for seizure disorder identified.
2. Specifically, no MRI evidence of mesial temporal sclerosis, malformation of cortical development, or epileptogenic tumor.
(Example Positive Impression for MTS)
1. Findings consistent with left mesial temporal sclerosis, characterized by left hippocampal volume loss and T2/FLAIR hyperintensity. This is a likely structural correlate for the patient’s seizure disorder.
4. Free Radiology Report Template Sources
Building out your personal macro library is a rite of passage. Before you reinvent the wheel, know that two great free repositories exist, curated by radiologists for radiologists. They are an excellent starting point for building out your templates for this and other studies.
- RadReport.org: Maintained by the RSNA, this is a comprehensive library of peer-reviewed templates covering nearly every modality and subspecialty.
- Radiology Templates (AU): A fantastic, user-friendly site maintained by Australian radiologists with a clean interface and practical, ready-to-use templates.
5. The Next-Level Move: From Free-Form Dictation to a Structured Report
The real bottleneck on a busy shift isn’t dictating the findings—it’s formatting them into a clean, structured report that your attending and the referring clinicians can quickly digest. This is especially true for complex studies like an epilepsy protocol MRI where multiple specific negative and positive findings need to be documented.
Instead of toggling between your dictation window and a template, you can dictate the positive findings in free form and let an AI tool handle the rest. GigHz Precision AI is designed to do exactly this. You dictate “Left hippocampal volume loss and T2 hyperintensity,” and the platform generates a fully structured report using pre-loaded ACR and SIR templates. It helps surface the need for specific classifications and can integrate Clinical Decision Support (CDS) where appropriate, streamlining the process of creating a high-quality, attending-ready report.
6. When Should You Order an MRI Brain for Seizure? ACR Appropriateness Criteria
Deciding on the right initial imaging is a common question from the ED and neurology services. The American College of Radiology (ACR) provides clear guidance. For both the “Seizures and Epilepsy” and “Seizures-Child” topics, a dedicated brain MRI is the first-line, highest-rated modality.
For an adult with a new-onset seizure, whether related to trauma or not, an MRI of the brain is rated 9/9 and is Usually Appropriate. The same applies to patients with a known seizure disorder who present with a change in seizure type, a new neurologic deficit, a history of tumor, or are being considered for surgery.
In the pediatric population, the guidance is similar. For most initial seizure workups—including neonatal seizures, complex febrile seizures, post-traumatic seizures, and new focal seizures in children—an MRI of the brain is rated 8/9 and is Usually Appropriate.
While MRI is the primary tool, alternatives may be considered in specific scenarios. FDG PET/CT can help identify an occult focus of cortical dysplasia not visible on MRI. Ictal SPECT or magnetoencephalography (MEG) are functional studies used for pre-surgical localization. For a hemodynamically unstable patient in status epilepticus or with a suspected acute hemorrhage, a non-contrast head CT is the appropriate first step for its speed and accessibility.
7. MRI Brain Seizure/Epilepsy Imaging Protocol — Sequences, Contrast, and Key Parameters
A dedicated epilepsy protocol is not the same as a routine brain MRI. The key is thin-slice, high-resolution imaging through the temporal lobes, specifically angled to properly evaluate hippocampal anatomy. The technologist must align the coronal slices perpendicular to the long axis of the hippocampus.
The protocol is designed to maximize sensitivity for subtle structural abnormalities. Below is a typical sequence list.
| Sequence | Plane | Slice Thickness | Key Purpose |
|---|---|---|---|
| T1 3D MPRAGE | Sagittal | 1 mm isotropic | Anatomy, volumetric analysis (e.g., FreeSurfer) |
| T2 FSE | Axial | 3-4 mm | General pathology |
| T2 FLAIR | Axial | 3 mm | Edema, gliosis, cortical lesions |
| DWI/ADC | Axial | 5 mm | Ischemia, cellularity (ictal changes) |
| T2 FSE High-Res | Coronal | 3 mm | Pivotal: Hippocampal internal architecture |
| STIR or T2 FLAIR | Coronal | 3 mm | Pivotal: T2 hyperintensity in MTS |
| SWI | Axial | 3 mm | Hemorrhage, calcium (cavernoma) |
| 3D FLAIR (Optional) | Isotropic | 1 mm | Cortical malformation detection |
Common protocol pitfalls:
The use of contrast is variable. For a pure epilepsy workup where tumor or infection is not suspected, a non-contrast study is often sufficient. However, if there is any concern for a neoplasm or inflammatory process, post-contrast images are essential. Additionally, 3D isotropic acquisitions like MPRAGE and 3D FLAIR are becoming standard; they allow for multiplanar reformatting, which is invaluable for tracing a subtle band of heterotopic gray matter or delineating the “transmantle sign” in focal cortical dysplasia.
8. The 3-Months-Free Offer for Residents and Fellows
3+ months free for radiology residents and fellows
Look like a rockstar on your reports — dictate positive findings in free form, and the AI generates a structured report using ACR + SIR templates with the appropriate clinical decision support firing automatically. All we ask in return is feedback so we can keep improving the product for trainees.
Signup is simple. No credit card, no long forms. To get started, just provide these three items:
- Your PGY year (e.g., PGY-2, PGY-4)
- Your training type (radiology residency or specific fellowship)
- Your training program / hospital name
Ready to give it a try? Apply for the residents free-access program and we’ll get you set up.
9. Frequently Asked Questions
Is GigHz Precision AI HIPAA-compliant?
Yes. The platform is designed for de-identified workflows by default. No patient-identifying information (PHI) is required to use the tool, ensuring compliance with institutional and federal privacy standards.
Does this require a complex IT setup?
No. GigHz Precision AI is browser-based and requires no local software installation. It works on any hospital workstation, personal laptop, or even the call-room iPad. There is no need to get your IT department involved.
Does it work with PowerScribe or other dictation systems?
Yes. It works alongside any existing dictation system. You dictate as you normally would, and use the tool to help structure and finalize your report before signing. The final structured text can be easily copied and pasted into your PACS/RIS.
Can I use it on my phone or iPad?
Absolutely. The platform is fully responsive and designed to work on any device, which is perfect for reviewing a report or checking a template on the go.
Can I customize the templates?
Yes. While the system comes pre-loaded with standard ACR and society-level templates, you have the ability to create, modify, and save your own custom templates to match your personal or institutional preferences.
What happens after my residency or fellowship ends?
We offer continuity plans for graduating trainees who want to continue using the platform in their practice. Your custom templates and settings are saved to your account.
Free GigHz Tools That Pair With This Article
Three free tools that complement the material above:
- ACR Appropriateness Criteria Lookup — Type an indication or clinical scenario in plain language and get the imaging studies the ACR rates for it, with adult and pediatric radiation levels. Built directly from 297 ACR topics, 1,336 clinical variants, and 15,823 procedure ratings.
- GigHz Imaging Protocol Library — A searchable library of 131 imaging protocols with the physics specs surfaced and the matching ACR Appropriateness Criteria alongside. Plain-English narratives readable in 60 seconds, organized by modality.
- GigHz Radiation Dose Calculator — Pick the imaging studies a patient has had and see total dose in millisieverts (mSv) with comparisons to natural background radiation, transatlantic flights, and chest X-rays. Useful for shared decision-making.
Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 7, 2026
