What is the next step in managing a middle-aged hypertensive male with increasing forgetfulness and frequent falls, and a negative computed tomography (CT) head scan?

MRI Brain Without and With Contrast is the Next Step

In a middle-aged hypertensive male with progressive forgetfulness and falls after a negative CT head, proceed directly to MRI brain without and with contrast to detect occult pathology that CT cannot visualize. 1

Why MRI is Essential in This Clinical Scenario

CT Limitations in Cognitive Decline with Falls

• CT head has significant limitations for detecting the subtle pathology causing cognitive impairment and falls in hypertensive patients, including small vessel ischemic changes, microinfarcts, white matter disease, and early hypertensive encephalopathy 1

• Hypertension causes specific brain injury patterns that CT frequently misses: narrowing and sclerosis of small penetrating arteries leading to subcortical white matter demyelination, microinfarction, and cognitive decline 1

• MRI detects subcortical white matter lesions and microinfarcts that are common in chronic hypertension and directly correlate with cognitive impairment and falls—these are often invisible on CT 1

High-Risk Features Present in This Patient

• History of falls is a critical red flag that significantly increases the likelihood of intracranial pathology requiring identification, even when CT appears normal 1, 2

• Hypertension combined with falls and cognitive symptoms represents a high-risk constellation: falls are associated with subdural hematoma, ischemic stroke, and hypertensive encephalopathy—all of which may be occult on CT but visible on MRI 1

• Progressive forgetfulness in a hypertensive patient suggests evolving vascular cognitive impairment, which MRI can characterize through detection of white matter hyperintensities, lacunar infarcts, and microhemorrhages 1, 3

MRI's Superior Diagnostic Yield

• MRI changed clinical management in 76% of patients with altered mental status in a prospective study, including revised diagnoses (20%), revised levels of care (21%), and improved diagnostic confidence (43%) 1

• 70% of missed ischemic strokes presented with altered mental status, and MRI was superior to CT in detecting these small ischemic infarcts 1

• MRI without and with contrast is specifically indicated when intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected—all relevant differential diagnoses in this presentation 1

The Specific MRI Protocol Needed

• Order MRI brain without and with IV contrast to definitively characterize any focal lesions and evaluate for tumor, infection, inflammatory conditions, or vascular abnormalities 1

• The contrast component is essential because this patient's presentation could represent an underlying mass lesion, metastases, or inflammatory pathology that requires contrast enhancement for detection 1

• MRI is superior to CT for detecting posterior reversible encephalopathy syndrome (PRES), which can present with cognitive changes and falls in hypertensive patients 4, 5

Why Not the Other Options

Genetic Testing (Option b) is Premature

• Genetic testing has no role before structural imaging is complete—you must first exclude treatable structural causes like subdural hematoma, tumor, stroke, or hypertensive encephalopathy 1

• Genetic causes of dementia (e.g., familial Alzheimer's, CADASIL) are diagnoses of exclusion made only after neuroimaging and metabolic workup are unrevealing

Ceruloplasmin (Option c) is Not Indicated

• Wilson's disease screening with ceruloplasmin is appropriate for young patients (<40 years) with unexplained neuropsychiatric symptoms, movement disorders, or liver disease—not for middle-aged hypertensive patients with falls

• This patient's presentation is classic for hypertensive cerebrovascular disease, making Wilson's disease extremely unlikely and ceruloplasmin testing a distraction from the correct diagnosis

Critical Clinical Pitfalls to Avoid

• Do not dismiss a negative CT as ruling out significant pathology in a hypertensive patient with cognitive decline and falls—CT misses the majority of small vessel disease, microinfarcts, and early hypertensive encephalopathy 1

• Do not delay MRI while pursuing metabolic or genetic workup—structural lesions requiring urgent intervention (subdural hematoma, tumor, stroke) must be excluded first 1

• Do not assume falls are simply "mechanical" or orthostatic—in hypertensive patients with cognitive symptoms, falls often indicate cerebellar involvement, posterior circulation ischemia, or evolving hypertensive encephalopathy 4, 2

Additional Workup Considerations

• While awaiting MRI, check basic metabolic panel, complete blood count, thyroid function, and vitamin B12 to exclude reversible metabolic causes of cognitive impairment 5

• Document orthostatic vital signs to assess for orthostatic hypotension from antihypertensive medications, which can contribute to falls 1

• Review medication list for drugs that impair cognition or balance (anticholinergics, benzodiazepines, antihypertensives causing orthostasis) 1