INTRODUCTION: With improved imaging technology, the number of incidental findings detected in cerebral MRI is increasing. This is a challenge that the German Air Force has to deal with in the context of standardized MRI examinations of young pilot candidates and pilots.METHODS: The German Air Force Centre of Aerospace Medicine hosted a 2-d conference to develop recommendations and procedures for the handling of some of the most frequently encountered cerebral incidental findings.RESULTS: Radiological MRI findings from a total of 2724 routine examinations of the skull of pilots and pilot applicants (26.8 ± 10.6 yr old; range from 16 to 62; over 80% range from 17 to 33; 96% men) revealed that in 28.1% of the examinations, one or more incidental findings were discovered. For seven of the following categories of incidental findings, decision guidelines could be established: white matter hyperintensities (N = 393; prevalence 14.4%; 95% CI 13.11-15.75), pinealis cysts (317; 11.6%; 10.43-12.84), developmental venous anomalies (64; 2.3%; 1.78-2.92), cavernomas (15; 0.6%; 0.27-0.83), aneurysms (14; 0.5%; 0.25-0.78), cholesterol granulomas (22; 0.8%; 0.47-1.14), and heterotopias of the gray matter (6; 0.2%; 0.04-0.4).CONCLUSION: Considering pilots health and aviation safety, a waiver decision is often possible after thorough discussion, depending on the specific criteria of the incidental finding and of the type of license.Kühn S, Sönksen S-E, Noble H-J, Knopf H, Frischmuth J, Waldeck S, Müller-Forell W, Weber F, Bressem L. Incidental findings in head and brain MRI of military pilots and applicants: consequences for medical flight fitness. Aerosp Med Hum Perform. 2022; 93(5):450-457.