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I'm Dr. Pomeranz

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here with neuroradiologist, Dr. Ben Lasar.

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And we are looking at a 77-year-old man

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with memory loss, cognitive decline,

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and also some mild motor dysfunction.

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The patient also had the history to rule out MS and

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rule out ALS or amyotrophic lateral sclerosis.

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On the left-hand side of the screen,

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we've got an axial conventional fast spin echo T2.

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There's extensive periventricular white matter hyperintensity.

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We also see innumerable hyperintense,

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little speckled foci in the inferior

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portion of the brain subfrontally,

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and in the basal ganglia, consistent with État criblé,

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which we'll explain.

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In the center,

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we've got a fluid-attenuated inversion

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recovery or a FLAIR,

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again demonstrating rather profound

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periventricular hyperintensity,

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but relative sparing of the temporal regions,

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especially the peritemporal white matter,

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which is important.

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And then on the far right,

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a susceptibility-weighted or blood-sensitive sequence,

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also known as SWI or Swan,

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which shows no evidence of siderotic change

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or hemorrhage.

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So, given the negative appearance of the susceptibility

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weighted sequence on the far right,

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what would be your differential diagnosis?

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Given the patient's history of memory symptoms,

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and cognitive impairment,

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my first differential consideration would include

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small vessel dementia,

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also known as Binswanger,

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also known as subcortical arteriosclerotic encephalopathy.

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And you know

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this is a condition which is an overlap condition

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related to underlying hypertension

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and underlying arteriosclerosis.

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And granted hypertensive patients

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do get little punctate hemorrhages

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in the perforating vessels, lenticulostriates,

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the thalamostriates,

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the perforators of the brain stem, et cetera.

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This patient doesn't have that,

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nor does the patient have evidence of

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lobar hemorrhages of varying ages,

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which you would see in amyloid,

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which might also be a consideration and is often

1:54

commingled with other vascular disorders.

1:57

Now, there's very extensive confluent white matter

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signal alteration, but on the axial T2,

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there are multiple speckly,

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or what I call twinkly little dots of hyperintensity.

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And you can see them in the subfrontal region.

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You can even see them a little bit in the brainstem,

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but mostly in the basal ganglia.

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And this is typical of the entity

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known as État criblé,

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where you have elevated blood pressure producing

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expansion of the perivascular spaces,

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a combination of underlying

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hypertension and arteriosclerosis,

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producing what we call the Binswanger's phenomenon.

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What's in the differential diagnosis here?

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Differential diagnosis for this type of appearance would

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also include MCI, Mild Cognitive Impairment Syndrome,

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or even early Alzheimer's.

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You could throw in the differential consideration.

2:45

Sure.

2:46

And I think you could consider that,

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and then I would probably throw it out.

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Now, 15% of all dementias are both vascular

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and neurodegenerative.

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But look how good the entorhinal cortex looks.

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It's not perfect, but it certainly

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not nearly as affected as the rest of the brain.

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So with this juicy entorhinal cortex

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and so much other disease elsewhere,

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that wouldn't be a strong choice of mine.

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Now, they asked us to rule out MS

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for I don't know what reason,

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but the fact that we've got sparing of the occipital

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region or less involvement of the occipital region,

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and the fact that we have very little to no

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periventricular white matter disease,

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and the fact the patient is a man,

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and he's in his 70s,

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that's probably a silly consideration.

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I think they were concerned about ALS because there is

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some change along the left corticospinal tract and

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that was not unreasonable from a clinical standpoint.

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But he's got severe gliosis in the brainstem pons.

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You kind of see it right,

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let's see if I can get to it.

3:45

Right here.

3:47

Maybe not severe,

3:48

but definitely present, these areas of high signal.

3:51

So, the combination of pontine disease and left

3:53

corticospinal tract disease might have led them to

3:56

that diagnosis.

3:57

And you can get ALS at any age.

3:59

It's usually bilateral. It isn't this lumpy,

4:02

bumpy appearance,

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but rather one long strand-like area of hyperintensity.

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And he certainly doesn't have that.

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And you could use fiber tracking,

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which we do have to assess the status

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of the corticospinal tract.

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And we'll do that on the next vignette.

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So, this is subcortical arteriosclerotic encephalopathy

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or Binswanger syndrome.

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Incidentally noted,

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he's had both lenses replaced and there are a

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few other minor findings.

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Shall we move on?

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Let's.

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Let's. Pomeranz and Laser out.