0:00

Dr. Laser,

0:01

we've got a 64-year-old woman with memory loss

0:04

for one year, you know, rather profound.

0:06

And thus she was unable to hold

0:09

still in the scanner.

0:09

But we are still able to get a study,

0:11

T2 axial fast spin echo FLAIR in the middle,

0:14

and diffusion study on the far right.

0:17

B value approximately 1000.

0:19

And I sense that there's going to be some hockey.

0:23

I don't know if you were a nice hockey player,

0:25

but I sensed some hockey coming on here

0:27

and a hockey stick sign,

0:28

which I'll leave to you in a moment.

0:30

But it's sort of weird.

0:31

You have bilateral caudoputaminal hyperintensity.

0:35

And, by the way, these won't enhance at all.

0:38

They're just kind of sitting there.

0:39

And they do sit there.

0:41

You've got bilateral thalamic signal alteration.

0:44

You've also got some signal alteration in the

0:46

cortex, which is hard to see on the conventional

0:49

portion of the examination.

0:51

But when you go over to the diffusion restriction

0:53

portion of the study, caudate involved,

0:55

putamen involved, thalamus involved,

0:58

and how would you describe

1:00

that thalamic involvement?

1:01

So you have medial thalamic involvement and

1:03

you have pulvinar thalamic involvement.

1:06

And when you put the two together,

1:07

it almost looks like a hockey stick.

1:09

Your long shaft is the medial aspect of the

1:12

thalamus, and then your pulvinar is your...

1:14

the short end of the stick.

1:16

So we have both.

1:17

We also have another sign in the cortex.

1:19

If we go up a little bit higher on the diffusion

1:21

restriction portion of the study,

1:22

I'll zoom out a little bit.

1:24

What do you think of the cortex?

1:26

You have this intrinsic diffusion-weighted

1:30

cortical ribbon hyperintensity on the diffusion

1:33

weighted sequence,

1:34

and it's the cortical ribbon sign.

1:36

And it's bilateral, too.

1:37

It's in the right frontal as well as

1:39

the mesial left frontal area.

1:42

Now,

1:43

this is typical of somebody with

1:46

CJD or Creutzfeldt-Jakob disease.

1:49

There is one other disorder that is a slow-acting

1:53

viral-type infection that affects humans and

1:56

that is transmissible mink encephalopathies.

1:58

You see it in people that strip the...

2:01

strip the coats off minks in Russia.

2:03

We don't see it much in this country.

2:04

And then there are others that affect animals and

2:07

other syndromes that are not affecting humans,

2:10

like Gerstmann-Sträussler-Scheinker syndrome,

2:13

Kuru, and Scrapie.

2:14

So the one that you have to be

2:15

most concerned about is CJD.

2:18

You've described the hockey stick sign,

2:21

the pulvinar sign, the ribbon sign,

2:24

the fact that it's diffusion-restricted,

2:26

the fact that it's on the FLAIR, and the T2,

2:28

that it changes very, very slowly,

2:30

if at all, over time.

2:31

The fact that it doesn't enhance all these things

2:34

along with the symmetry of it,

2:36

go on to support the diagnosis

2:38

of a prion-mediated disorder.

2:40

So in the next vignette,

2:41

we'll talk a little bit about CJD.

2:43

Do you have any other comments about the

2:44

MRI findings that we see in this case?

2:46

Okay, let's move on then.

2:47

Laser and Pomeranz out.