0:00

This patient was an 84-year-old who

0:03

is being evaluated for dementia.

0:05

Scrolling through this case,

0:08

if we focus initially on the T2-weighted scan,

0:11

we see areas of infarction in the cerebellum,

0:17

as well as within the brainstem,

0:19

and we see that the brainstem is actually quite small inside.

0:22

There's been some element of atrophy.

0:25

We also see the involvement of the

0:27

middle cerebellar peduncle.

0:29

As we continue further superiorly and convert

0:33

to starting to look at the FLAIR image,

0:36

we see bilateral thalamic areas of infarction,

0:40

as well as a relatively diffuse involvement

0:43

of the basal ganglia and the thalamus

0:46

on T2-weighted and FLAIR imaging.

0:49

The white matter disease is relatively

0:52

confluent and is diffuse and extends

0:55

throughout the white matter of the frontal lobes

0:59

as well as lower down in the parietal

1:04

and occipital regions,

1:05

and the patient shows ventricular dilatation.

1:08

On postgadolinium-enhanced scans

1:12

you can see that there are no areas

1:15

of contrast enhancement.

1:17

So this patient has a rip-roaring involvement

1:20

of what we would say is atherosclerotic

1:24

leukocencephalopathy with lacunar infarctions.

1:28

In this particular case,

1:29

the patient did carry the diagnosis of

1:31

Binswanger's disease, which, as I mentioned,

1:34

the common denominator here is the severe

1:37

hypertension with the encephalopathy associated

1:42

with the white matter disease,

1:44

as well as the deep gray matter involvement

1:47

and lacuna infarctions.

1:52

The anterior temporal lobes are not involved

1:55

like they are with CADASIL in patients who have

1:59

Binswanger's disease.

2:01

Now, this patient is a little bit unique,

2:04

in that the amount of hemorrhage within the brain

2:08

is quite striking.

2:10

In fact, in this patient,

2:13

because of the number of microhemorrhages,

2:16

we might raise the possibility

2:18

of amyloid angiopathy.

2:22

Amyloid angiopathy can lead to multiple

2:25

hemorrhagic foci in the brain

2:28

with hemosiderin deposition.

2:30

It may also cause focal lobar

2:34

hemorrhages or infarctions.

2:36

This patient does not have focal

2:38

lobar infarctions.

2:39

In addition,

2:40

you see that the patient has involvement of

2:44

the thalamus and basal ganglia with

2:47

these hemorrhages.

2:48

By and large,

2:49

amyloid angiopathy,

2:51

as opposed to a hypertensive encephalopathy,

2:53

is more likely to have peripheral hemorrhages

2:57

rather than deep gray matter thalamic basal ganglia

3:00

and brainstem hemorrhages,

3:02

which is what you're seeing here in this

3:05

susceptibility weighted scan on this patient.

3:09

So, it is likely that these hemorrhages are more

3:12

likely to represent a manifestation of

3:15

hypertension in the setting of a patient with

3:17

Binswanger's disease

3:18

than it is for amyloid angiopathy.

3:22

Amyloid angiopathy is an entity that we are

3:26

seeing much more frequently because of the

3:29

susceptibility weighted images scan,

3:32

sensitivity to the presence of blood products,

3:35

where we see lots of hemorrhages

3:37

in the periphery.

3:39

So, again, to distinguish amyloid angiopathy

3:41

from hypertensive encephalopathy,

3:44

we look and see where the hemorrhages are,

3:46

whether or not there's deep gray matter

3:48

or brainstem involvement,

3:49

which would favor hypertension,

3:51

whether or not there's a focal lobar hemorrhage,

3:54

which is more common with amyloid angiopathy,

3:57

and whether or not there is

3:58

hemosiderosis of the pia,

4:01

which occurs much more frequently

4:03

in amyloid angiopathy.

4:05

In any case,

4:06

this is a patient with Binswanger's disease,

4:08

with hypertension and hypertensive bleeds,

4:12

leading to hypertensive encephalopathy

4:14

with Binswanger's disease.