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Dr. Laser, this is an 80-year-old female.

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She's got severe numbness,

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balance disturbance, dizziness,

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numbness, speech disturbance, and hearing loss.

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And a partridge in a pear tree.

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And it's no wonder she's got multiple things going on.

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And one of our tasks here is to sort

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of define vascular dementia.

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And a second key teaching point is to tease out the

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different components that might be

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contributing to her symptoms.

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And the third point is to pick out any incidental

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findings that may or may not be contributory.

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So, I'd like to start out by just saying

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what we have up here.

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We've got an axial T2 paired on the right.

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We've got a susceptibility weighted image that's going to

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bring out the appearance of iron and blood and siderosis.

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In the middle, we've got a sagittal FLAIR,

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which demonstrates obvious confluent

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white matter hyperintensity.

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So, I'd like to start out

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by just defining some vascular dementias.

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We said that was going to be one of our jobs,

0:58

one of our goals in this vignette,

1:00

hypertension with siderosis.

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We do not have siderosis over here, so that one's out.

1:05

Hypertension with État criblé lacunaire

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or dilated perivascular spaces.

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We do have some of those in the pontine perforators,

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and we have pontine gliosis.

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So the brain stem is affected,

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but the usual loci of extensive stippled Virchow-Robin

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or perivascular space hyperintensity is not present.

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And sometimes, those can get really weird.

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When they're around the temporal region,

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I've seen them very cystic,

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and it's these perivascular spaces that can have

1:32

FLAIR hyperintensity around the outside.

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The rest of them do not.

1:36

Then we've got amyloid,

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where we've got peripheral low bar

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and/or microhemorrhages with infarcts.

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This patient doesn't have that on the SWI or Swan,

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or BSI image.

1:46

Then you've got small vessel disease,

1:49

subcortical arteriosclerotic encephalopathy,

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which consists of deep confluent periventricular white

1:56

matter signal without peripheral macro infarction.

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And you can use the physique of scales we've discussed

2:03

before to gauge the white matter disease present.

2:05

And that fits very well here.

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Then we've got the entity known as CADASIL,

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which looks identical to SAE, but is hereditary.

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Seen in men a little more than women,

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associated with headache, patients a little old for it,

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and the white matter disease is not

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as confluent as we would see here.

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And then we've got classic multi-infarct dementia,

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in which I'm really looking for wedge-shaped infarctions,

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you know, macro-infarctions,

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in association with small vessel disease.

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We don't have that here.

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So I differentiate the Binswanger pure small

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vessel variety, which we have here,

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from the medium to large vessel variety,

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which is multi-infarct dementia,

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where you have multiple infarcts, various ages,

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various territories.

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Then finally, we've got vasculitis,

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which wouldn't fit here.

2:54

We've got vasculocerebrotic inflammation

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that may or may not diffusion restrict,

3:00

usually does not and is associated with severe

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headache and some other symptomatology and probably

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wouldn't apply in this 80-year-old,

3:08

even though the symptoms were rather complex.

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Now, we also said that we would define other findings.

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And here we've got a meningioma anteriorly.

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I don't think that plays much of a role in this case,

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so we'll ignore it for now.

3:22

We can see it in the sagittal projection.

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This one has gone into the calvarium.

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It's very dense, thick-looking, intermediate signal,

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bland-looking.

3:30

And we've also got another interesting incidental finding,

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which is an empty sella.

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And the only thing that might play into dementia with this

3:40

incidental finding is sometimes you can get

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older individuals who are under stress,

3:45

that are low in cortisol or low in thyroid

3:48

hormone as a result of this,

3:50

and this can compound and complicate their dementia.

3:54

So now, I want to go on to the third major point that we

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want to make, which is, what's this patient have?

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How many types of dementia are there present?

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And knowing that this patient, by history,

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has Parkinson's disease,

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which is the dominant or codominant dementia contributing

4:12

to these symptoms, and we'll do that in the next vignette.

4:14

Shall we?

4:14

Let's do it.

4:15

All right, Pomeranz and Laser out.