This 52-year-old right-handed female presented with a 10-year history of cognitive decline, heralded by difficulty concentrating, along with mild depression and anxiety. Despite improvement of her mood with antidepressant medication, her ability to focus continued to deteriorate. Within a few years, she exhibited difficulty with multitasking, affecting her performance at work as a petrographer. She could still manage her basic activities of daily living, but they demanded more effort than before. Relevant medical history included migraines with aura and hypertension, which had been under good control for the past eight years. She was taking bupropion 450 mg and amlodipine 5 mg daily. Her family history was relevant for stroke in her mother in fifties and migraine in her mother and sister. The neurological examination was remarkable for brisk reflexes and difficulties with tandem gait. Neuropsychological evaluation revealed impairment of executive abilities, including processing speed, task switching and working memory, as well as impairments in memory encoding and retrieval. Brain MRI showed extensive, symmetric, white matter changes (Figure 41.1).