0:00

Dr. Laser,

0:01

This is a 68-year-old man who I know personally.

0:03

He's a money manager.

0:04

Things aren't going so well at work as he's having

0:06

trouble doing math and just remembering

0:08

things in general.

0:09

So, he's clearly got a form of cognitive decline.

0:13

As we scroll the coronal projection,

0:16

we look at the size of the temporal horns.

0:18

They're big.

0:19

The choroidal fissures, they're big.

0:21

And the hippocampus is a little bit lobulated

0:24

instead of nice and generous and convex upward.

0:27

It's starting to demonstrate this mogul-like appearance.

0:31

Down you go into the trough,

0:32

up you go onto the top of the mogul,

0:34

and then down again.

0:35

You really shouldn't have that.

0:37

And of course,

0:37

there are a lot of structures in here,

0:38

like the fimbria and the subiculum

0:40

and the hippocampus and the dentate gyrus,

0:43

which you can sort out with high

0:45

resolution coronal imaging.

0:46

So he's got a medial temporal atrophic

0:49

score of at least two.

0:50

Correct. Yeah.

0:51

So...

0:52

And the number one biomarker on imaging for

0:55

ALZ is the degree of hippocampal loss.

0:58

Never mind that you're looking at parietal

1:01

atrophy and temporal atrophy in general,

1:03

and also a Sylvian atrophy.

1:05

Now, most patients with typical Alzheimer's disease

1:08

don't have as much frontal atrophy as

1:10

they do temporal parietal atrophy.

1:12

But perhaps a more specific way to go about

1:16

including Alzheimer's disease in the diagnosis,

1:18

besides the things we mentioned,

1:20

namely hippocampal atrophy,

1:21

as the number one biomarker,

1:22

is excluding other common causes of dementia.

1:26

One of them is vascular disease.

1:28

So, what would you grade this according to the

1:31

Fazekas scale for vasculopathy or white matter disease.

1:35

So for a 68-year-old gentleman,

1:37

he has some punctate white matter foci,

1:41

this would be a scale of a score of 1.

1:43

So, not much.

1:44

Not much.

1:44

Now, this would be normal for a patient of this age.

1:46

Yeah, and he doesn't have any macro infarctions,

1:49

so it'd be hard to explain his cognitive

1:51

decline based on vascular etiology.

1:53

So that's one we can toss aside.

1:55

There isn't a lot of olfactory or frontal atrophy

1:58

compared to the other distributions.

2:00

He also doesn't have disinhibition,

2:02

bad behavior, dysexecutive syndrome.

2:04

So that moves us away from frontal lobar

2:07

dementia or pick's like syndromes,

2:10

of which there are three or four different

2:11

diseases that have been described.

2:13

Doesn't have visual hallucinations,

2:15

also doesn't have tremor.

2:17

So that takes us away from Lewy Body Dementia.

2:20

Now, I just want to talk for a minute about the

2:23

cingulum in the sagittal projection.

2:25

Let's bring down the sagittal.

2:26

We look at this cingulum and the cingulate sulcus.

2:29

It is big. It's not huge, but it's big.

2:32

And then the parietal occipital sulcus is big.

2:36

Not huge, but big.

2:37

And so that would go along with Alzheimer's disease.

2:40

It's not pathognomonic.

2:42

Now, one thing that is helpful in excluding

2:44

ALZ is doing Fluorodopa PET.

2:48

And there are a number of agents

2:50

that are available.

2:51

The presence of enhancement on Fluorodopa PET,

2:54

which I don't have here,

2:55

is not very specific.

2:56

You can see it in aging.

2:59

You can see it in some other disorders,

3:00

but the complete absence of any uptake in a

3:03

brain with Fluorodopa PET is highly specific,

3:06

very good negative predictive value for

3:10

the absence of Alzheimer's disease.

3:12

So, if you got a 45-year-old with some cognitive

3:15

decline and you want to absolutely exclude ALZ,

3:19

that is one way to do it.

3:21

Now, you and I have both discussed before

3:23

that the number one biomarker for ALZ

3:26

is the size of the hippocampus,

3:28

and this hippocampus is pretty small.

3:30

Unfortunately,

3:31

this patient did go on within a year to full-blown ALZ.

3:35

12% of cognitive impairment patients

3:38

without strict Alzheimer's criteria

3:40

do go on in one year and 80% by 5 years.

3:44

Are there any other comments

3:45

you'd like to make on this case?

3:46

The one comment I would like to discuss would

3:49

be the putting the whole picture together,

3:51

looking at the global cortical atrophy scale,

3:53

which we've talked about in a prior vignette,

3:55

the parietal lobe atrophy.

3:56

We talked about the temporal lobe atrophy

3:59

and then coming up with a diagnosis.

4:01

If this patient presents with impaired

4:02

cognition as his first scan,

4:04

the most important thing you can do

4:06

is to say temporal lobe atrophy,

4:09

suspicious for Mild Cognitive Impairment Syndrome,

4:11

such early Alzheimer's,

4:13

and recommend follow-up imaging to assess

4:15

progression of disease or stability of the disease.

4:17

Great. Pomeranz and Laser out.