0:00

Dr. Laser,

0:01

this is an 82-year-old man

0:02

with a Parkinson's syndrome,

0:04

pretty severe, and dementia.

0:06

I'm of the school that I take what they give me.

0:09

You know,

0:10

they gave me an important piece of information,

0:12

Parkinson's syndrome.

0:13

What are the conditions that you start to

0:16

drill into and tease out of this case?

0:18

So, things to think about would be,

0:20

obviously, Parkinson's syndrome,

0:21

MSA, Multisystem Atrophy.

0:23

Multisystem Atrophy.

0:24

Okay.

0:24

PSP,

0:24

Progressive Supranuclear Palsy.

0:26

LBD,

0:27

Lewy body dementia,

0:28

and Corticobasal degeneration, CBD.

0:30

Okay.

0:31

So now, let's start looking at this case.

0:34

And the first thing you notice on the sagittal is

0:37

that there is prominence of the

0:39

sulci almost everywhere.

0:40

And it's a little more prominent in the occipital region,

0:44

which is typical of this disorder.

0:46

Now, the parietal-occipital area may be

0:49

more involved in Alzheimer's too.

0:51

That's called Benson syndrome

0:52

when it's isolated back there.

0:54

But it's noteworthy that in LBD,

0:56

Lewy body dementia, that there is a

0:58

fair amount of atrophy back here.

0:59

And that's not the case with classic Parkinson's disease

1:02

and some of the other Parkinson's syndromes

1:05

until they get further down the line.

1:07

We saw a case of Picks's disease earlier

1:09

where the cingulum, the cingulate sulcus,

1:11

was profoundly dilated anteriorly.

1:14

And in Lewy body dementia,

1:16

it's more dilated near the margin as

1:18

it comes up to the Pars Marginalis.

1:20

If we go back to our Picks's case,

1:22

which I'm going to do right now, let's do that.

1:25

Let's look at the cingulate sulcus.

1:27

So, here it is.

1:28

Look at the profound atrophy of

1:30

the anterior cingulate sulcus.

1:32

And it fades as you go up to the Pars Marginalis,

1:35

exactly the opposite of Lewy body dementia.

1:38

Now, remember that Parkinson's disease can

1:41

be in the spectrum of Pick's disease.

1:43

There is a subtype called frontal lobar

1:46

dementia with Parkinsonian features.

1:47

So, you might have even lobbed that in as a 6th

1:50

one in the first five that you were given.

1:53

Let's go back to our Lewy body dementia case

1:56

and look at some of the other findings.

1:58

The patient has a generalized pattern of atrophy.

2:01

It doesn't have any specific distribution.

2:03

It's frontal, it's temporal, it's parietal.

2:06

How about the brain stem?

2:08

Looks pretty good.

2:09

It looks pretty good.

2:10

Cerebellum a little bit affected, but not much.

2:12

So, that takes away multisystem atrophy.

2:16

That takes away PSP,

2:18

Parkinson's plus syndrome.

2:19

So, we're starting to winnow the diagnosis down.

2:22

Let's look at the hippocampus.

2:24

The hippocampus and entorhinal cortex is involved,

2:26

although hard to tell without a good

2:28

coronal the extent of involvement.

2:30

So that doesn't necessarily get

2:32

ALZ out of the picture,

2:33

although the history of Parkinson-like

2:37

syndrome doesn't really point to ALZ.

2:39

Now, when you think about Parkinson's disease,

2:42

classic Parkinson's,

2:43

and you think about Lewy body dementia,

2:45

here's something that I found very helpful.

2:47

The motor symptoms,

2:49

the stiffness and/or the tremor precede the

2:54

other symptoms in Parkinson's disease,

2:56

including hallucinations and dementia.

2:59

Whereas in LBD,

3:01

the cognitive portion precedes the motor portion.

3:05

So that can be very helpful in the differential diagnosis.

3:08

Some of these other things,

3:09

the distribution in the cingulum,

3:11

the distribution in the parietal occipital region,

3:14

can also be helpful.

3:15

Another very helpful way to identify

3:18

LBD or Lewy body dementia,

3:20

which is the second most common form of

3:22

primary neurodegenerative dementia,

3:24

according to some,

3:25

anywhere from 15% to 25%,

3:28

is the clinical symptomatology of visual symptoms,

3:31

and this includes visual-spatial impairment

3:34

and especially visual hallucinations.

3:36

They have fluctuating cognition and arousal.

3:39

And as stated,

3:40

they have features of Parkinson's disease,

3:41

which we see here,

3:42

and executive dysfunction similar to

3:45

what we see in Pick's disease.

3:46

You can see there's a lot of overlap in these disorders,

3:48

but usually, one geography,

3:50

one symptomatology,

3:52

one type of chief complaint draws

3:55

you to the correct answer.

3:56

So, you can't just look at the picture.

3:58

You've got to have the patient's history and

4:00

the patient's clinical symptomatology.

4:02

Another interesting aspect of this case is the

4:05

iron store is a little more prominent in the basal

4:07

ganglia, but let's go to the compacta stripe.

4:10

The compacta stripe is effaced.

4:12

You know, there should be a round nodule

4:14

in the brain stem.

4:15

It's not really a nodule,

4:17

but if I draw a brain stem very quickly for you,

4:20

and you have your red nucleus,

4:22

and then you have your substantia nigra,

4:25

and in between right there,

4:26

you'd have your compacta stripe.

4:28

Whereas in Parkinson's syndromes,

4:30

including classic Parkinson's and some

4:32

Parkinsonian-like disorders,

4:34

including LBD and even MSA,

4:37

you may get these two bleeding together and

4:40

merging as one.

4:41

And I think we have that here.

4:42

We really can't separate them out very well.

4:45

So that would support a Parkinson-like syndrome.

4:48

And now, we have to decide Parkinson's disease

4:52

versus Lewy body dementia.

4:54

So that concludes our discussion for this vignette

4:56

of Lewy body dementia.

4:57

Pomeranz and Laser out.

4:58

Out.