What is the significance of cortical high attenuation in the right greater than left occipital lobes in an 89-year-old female (F) patient with a recent fall, and what are the implications of the computed tomography (CT) head scan findings?

From the Guidelines

The patient's CT findings suggest cortical laminar necrosis in the occipital lobes, and the next step should be a neurology consultation for further evaluation and management, as recommended by the most recent guidelines 1. The CT findings indicate cortical high attenuation in the right greater than left occipital lobes, which may represent laminar necrosis, a condition characterized by neuronal death in specific cortical layers following a hypoxic-ischemic event. Given the patient's age and the presence of chronic microvascular ischemic changes and age-related brain volume loss, it is essential to consider the potential for underlying vascular risk factors that may have contributed to the fall and the subsequent brain injury. The following steps should be taken:

• A comprehensive neurological examination to assess for visual deficits and other neurological symptoms given the occipital lobe involvement
• An MRI with contrast to confirm laminar necrosis and rule out other pathologies, as MRI is more sensitive than CT for subtle findings adjacent to the calvarium or skull base 1
• Investigation into the underlying cause of the possible hypoxic event, including cardiac workup to rule out arrhythmias or hypotensive episodes that may have contributed to the fall
• Monitoring for seizures, which can occur following cortical injury
• Initiation of supportive care and rehabilitation based on any functional deficits identified It is also important to note that the findings of chronic microvascular ischemic changes and age-related brain volume loss are incidental and common in elderly patients, requiring no acute intervention but suggesting the need for vascular risk factor management. According to the ACR Appropriateness Criteria for head trauma, head CT is highly sensitive for the detection of findings that may require neurosurgical intervention in the acute phase, and patients with a normal CT but with an abnormal neurologic examination are typically admitted for further observation and management 1. In this case, the patient's CT findings and clinical presentation warrant further evaluation and management by a neurologist to determine the best course of action.

From the Research

Patient's Condition

The patient, an 89-year-old female, experienced a recent fall from a toilet on 4/10. A CT head scan at an outside hospital revealed hyperdensity along the right parietal and left parietal occipital cortex, with soft tissue swelling/hematoma seen on the forehead and frontal scalp region.

Current CT Head Scan Findings

The current CT head scan shows:

• Cortical high attenuation in the right greater than left occipital lobes, which may indicate laminar necrosis 2, 3, 4, 5
• No acute intracranial hemorrhage or extra-axial fluid collection
• No regional loss of gray-white differentiation to suggest recent territorial infarction
• Patchy low attenuation within the cerebral white matter compatible with chronic microvascular ischemic changes
• Small hyperdense foci in the left basal ganglia, likely representing calcifications
• Enlarged ventricles, sulci, and cisternal spaces compatible with age-related parenchymal volume loss
• No hydrocephalus, midline shift, or other mass effect

Possible Diagnosis and Next Steps

Based on the CT head scan findings, the patient may be at risk for:

• Cortical laminar necrosis (CLN), a condition characterized by destruction of the cerebral cortex, mainly of the third layer, in situations of reduced energy supply to the brain 3
• Chronic microvascular ischemic changes, which may indicate a history of small vessel disease
• Calcifications in the basal ganglia, which may be related to hypoxia or other metabolic disturbances

The next steps in the patient's care may include:

• Close monitoring of the patient's neurological status and vital signs
• Further imaging studies, such as MRI, to confirm the diagnosis of CLN and to evaluate the extent of any potential brain damage
• Laboratory tests to rule out other potential causes of the patient's symptoms, such as infection or metabolic disturbances
• Consideration of prompt and aggressive treatment to prevent further brain damage and to improve the patient's outcomes 2