What is the diagnosis and management plan for an older adult patient with mild prominence of frontal cortical sulci, no evidence of acute hemorrhage or territorial infarct, and symptoms such as headache?

Diagnosis and Management of Older Adult with Mild Cortical Atrophy, Headache, and Normal Acute CT

This patient requires brain MRI without contrast as the definitive next imaging study to evaluate for neurodegenerative causes, vascular dementia, and other structural abnormalities not visible on CT, as MRI has superior sensitivity for detecting hippocampal atrophy, vascular lesions, microhemorrhages, and rare dementia causes that CT cannot visualize. 1

Primary Diagnostic Consideration

The mild prominence of frontal cortical sulci represents age-related cerebral atrophy, which is a common finding in older adults and may indicate underlying neurodegenerative disease or vascular cognitive impairment. 2 The CT scan has effectively ruled out acute hemorrhage and territorial infarction, but has limited sensitivity for detecting early neurodegenerative changes, hippocampal atrophy, and white matter disease. 1

Immediate Clinical Assessment

Headache Evaluation in Older Adults

• In patients 55 years or older with headache, particularly with acute onset or occipitonuchal location with associated symptoms, structural intracranial pathology must be excluded even with normal neurological examination. 3
• The preceding headache warrants careful evaluation as it may represent warning TIAs or evolving vascular pathology. 4
• Abnormal neurological examination findings have a 39% positive predictive value for intracranial pathology, but normal examination does not exclude significant disease in older adults. 3

Critical Associated Symptoms to Assess

Perform focused neurological examination looking specifically for: 1

• Left-sided weakness or sensory loss (suggesting right hemisphere stroke)
• Left-sided neglect or abnormal visual-spatial ability
• Gait abnormalities, extrapyramidal signs, or primitive reflexes
• Monocular vision changes or visual field defects

Advanced Imaging Strategy

Why MRI is Essential

MRI brain without contrast identifies specific atrophy patterns that suggest particular diagnoses: 1

• Medial temporal lobe atrophy for Alzheimer disease
• Frontal/temporal atrophy for frontotemporal dementia
• Ventricular enlargement patterns for normal-pressure hydrocephalus

MRI detects vascular pathology missed by CT: 2

• Focal lacunar infarcts and white matter hyperintensities (leukoaraiosis)
• Microhemorrhages indicating cerebral amyloid angiopathy or hypertensive vasculopathy
• Cortical or subcortical infarcts suggesting vascular cognitive impairment

Vascular Imaging Considerations

• If focal neurological deficits develop or stroke is suspected, CT angiography from aortic arch to vertex should be performed to assess extracranial and intracranial vasculature. 4
• If headache persists with any suspicion for cerebral venous thrombosis (CVT), obtain CT venography or MR venography, as standard CT may miss this diagnosis. 4

Laboratory Workup

Complete the following metabolic evaluation to identify reversible causes: 1

• Complete metabolic panel
• Thyroid function tests (TSH, free T4)
• Vitamin B12 level
• Complete blood count

Common Pitfalls to Avoid

• Do not assume normal CT excludes significant pathology causing symptoms—CT has limited sensitivity for early neurodegenerative changes and white matter disease. 1
• Do not delay MRI in favor of "watchful waiting" when progressive symptoms are present, as early diagnosis enables earlier intervention and planning. 1
• Do not dismiss persistent headache in older adults without thorough evaluation for secondary causes, especially in patients over 50. 4
• Do not assume primary headache disorder without definitive exclusion of stroke, hemorrhage, or mass lesion. 4

Incidental Findings Management

Sphenoid Sinus Mucosal Thickening

• Minimal mucosal thickening is a common incidental finding and typically does not require specific intervention unless symptomatic sinusitis is present.

Subcutaneous Calcification

• The punctate calcification in left temporal subcutaneous tissue is likely a benign finding (old trauma, calcified sebaceous cyst) and requires no specific management.

Follow-Up Imaging Considerations

If Alzheimer disease is diagnosed and antiamyloid therapy is being considered: 1

• MRI brain without IV contrast is mandatory before initiating treatment to identify pre-existing microhemorrhages and superficial siderosis that may preclude treatment
• Brain FDG-PET/CT may demonstrate characteristic temporoparietal hypometabolism
• Brain amyloid PET/CT can confirm presence of amyloid pathology if disease-modifying therapy is contemplated

If vascular dementia is suspected: 2

• MRI is preferable to CT for detecting vascular lesions
• Evidence of cortical or subcortical infarcts, leukoaraiosis, microhemorrhages, and lacunar infarcts supports the diagnosis
• Hippocampal atrophy may be present and is a predictor of post-stroke dementia