0:00

Dr. Laser,

0:01

we're here to talk about some of the

0:02

white matter changes that you see,

0:04

especially as they relate to dementia.

0:05

Now, in my experience and in the literature,

0:08

15% of all dementias are related to a primary

0:11

neurodegenerative disease of which ALZ,

0:13

or Alzheimer's is the most common.

0:15

And 15% are an ALZ-like condition

0:19

combined with vascular disease.

0:21

So two disorders going on at the same time.

0:24

It's important to try and sort out what component

0:27

is vascular and what component

0:29

is neurodegenerative.

0:30

For if most of it is vascular and not

0:32

neurodegenerative, in other words,

0:34

the atrophy is secondary to the vascular disease.

0:37

That patient might benefit from aggressive

0:40

treatment with Sandostatin ,

0:41

to reverse the effect of small vessel arteriopathy

0:44

and urvinopathy.

0:46

This patient, unfortunately,

0:47

has severe cortical atrophy in both the parietal

0:51

region but also in the frontal region.

0:53

We'll tackle that a little later.

0:54

But let's talk about the white matter

0:55

abnormalities and the Fazekas scale.

0:57

Sure.

0:58

So, Fazekas scale is a scale that typically

1:03

assesses the overall impression of the presence

1:05

of white matter disease in the entire brain.

1:07

The scale starts at zero,

1:09

which you would have normal brain parenchyma,

1:12

all the way to a three,

1:13

which you'd have large confluent lesions.

1:16

Fazekas 1

1:18

would be multiple punctate lesions.

1:21

So small punctate lesions scattered

1:23

throughout the white matter.

1:24

A Fazekas 2 would be the

1:26

beginning of confluency.

1:27

So the lesions would start to bridge and to

1:31

become patchy throughout the white matter.

1:33

And then 3,

1:35

the final assessment would be large confluent

1:39

lesions spanning the corona radiata,

1:42

the centrum semiovale,

1:43

white matter in the cerebral hemispheres.

1:45

So how would you rate this one as we scroll

1:46

up and down? Clearly not a three.

1:48

There's no big confluent lesions.

1:50

No.

1:50

In this one, I would probably give it a 1.

1:52

You have multiple punctate lesions.

1:54

There's no confluency.

1:55

There's no bridging.

1:56

There's no patchy,

1:57

big patchy areas of increased flair

2:00

signal within the white matter.

2:01

You have some along the ventricles,

2:02

which is called capping.

2:04

You have some in the corona radiata,

2:06

you have some in the centrum semiovale,

2:09

but nothing that's bridging or confluency.

2:11

So between a 1 and a 2.

2:13

Okay. And then on the right,

2:14

I put up the diffusion image,

2:16

and there's no diffusion restriction.

2:17

In other words,

2:18

there's no active ongoing infarctions.

2:21

That's the Fazekas scale in the

2:23

assessment of neurodegenerative disease.

2:25

This patient does have global cortical atrophy,

2:28

much worse on the left than right.

2:29

And that will be a story for an upcoming vignette.