Incidental Findings in Brain Imaging

White Matter Hyperintensities

A punctate white matter hyperintensity refers to a small, round to ovoid area that appears bright on T2-weighted or FLAIR MRI sequences, typically measuring at least 3mm in diameter, according to the Brain journal 1
Multiple lesions with specific distribution patterns, such as periventricular predilection or corpus callosum involvement, may be concerning 1
Lesions with ovoid shape and orientation perpendicular to ventricles, known as Dawson's fingers, may suggest demyelinating disease 1
A progressive increase in number or size of lesions over time is a concerning sign 3

Empty sella is typically an incidental finding on imaging studies performed for unrelated reasons, such as headache evaluation, and approximately 30% of patients with empty sella may demonstrate some hypopituitarism upon testing 2
Urgent workup is not necessary for a patient with an incidental finding of partially empty sella when there is no history or symptoms of pituitary dysfunction 2
Symptoms of pituitary dysfunction, such as fatigue, cold intolerance, or sexual dysfunction, may indicate a need for further evaluation 2
Visual changes or papilledema may also be a concern in patients with empty sella 2, 4
Signs of increased intracranial pressure, including headache, pulsatile tinnitus, or diplopia, should be evaluated further 4

Basic hormonal screening, including thyroid function tests, morning cortisol and ACTH, and sex hormones, may be necessary to rule out central hypothyroidism and assess adrenal axis in patients with empty sella 2
Ophthalmologic evaluation is recommended if there are any visual symptoms or concerns about increased intracranial pressure in patients with empty sella 2, 4

Attributing unrelated symptoms directly to incidental findings without considering more common causes should be avoided 2
Ordering unnecessary urgent tests that won't change immediate management is not recommended 2
Failing to recognize when these findings might be part of a more significant condition, such as pseudotumor cerebri, which would present with additional clinical and imaging findings, is a common pitfall to avoid 4, 5