From the Research
The approach to prominent cerebral sulci on MRI involves recognizing this finding as a potential indicator of cerebral atrophy or volume loss, and a systematic evaluation of the distribution, symmetry, and associated findings is crucial for accurate diagnosis and management. When prominent sulci are observed, radiologists should consider the following key points:
- Distribution: focal, lobar, or generalized
- Symmetry: asymmetrical sulcal prominence may indicate a focal lesion or pathology
- Associated findings: ventricular enlargement, white matter lesions, or other signs of cerebral atrophy The differential diagnosis should consider normal aging, neurodegenerative disorders (Alzheimer's disease, frontotemporal dementia) 1, vascular disease, prior trauma, hydrocephalus, and metabolic or toxic conditions. Correlation with clinical history is crucial, including cognitive status, neurological symptoms, and risk factors 2. Comparison with prior imaging helps determine if changes are progressive. Quantitative volumetric analysis may be helpful in borderline cases or for monitoring progression 1. When reporting prominent sulci, radiologists should avoid using the term "atrophy" without clinical correlation and should specify the pattern and severity of volume loss to guide clinical management and potential further workup.
Some key conditions to consider in the differential diagnosis include:
- Normal pressure hydrocephalus (NPH), which may present with ventriculomegaly and high convexity tight sulci 2
- Disproportionately enlarged subarachnoid space hydrocephalus (DESH), a distinct diagnostic imaging entity characterized by ventriculomegaly, high convexity/midline tight sulci, and enlarged sylvian fissures on brain MRI 2
- Alzheimer's disease, which may present with gray matter decrease and cerebral atrophy 1
- Vascular disease, prior trauma, and metabolic or toxic conditions, which may present with focal or diffuse cerebral atrophy and sulcal prominence.
In terms of management, patients with prominent cerebral sulci on MRI should undergo a comprehensive clinical evaluation, including cognitive and neurological assessment, laboratory tests, and imaging studies to determine the underlying cause of the sulcal prominence. Treatment should be tailored to the underlying condition, and may include shunting for NPH, medical management for Alzheimer's disease, or other interventions as needed. A recent study published in 2022 highlights the importance of considering spinal tumors in patients with NPH, and recommends holospinal MR imaging studies to rule out attendant spinal intradural extramedullary tumors before shunting 3.