Presentation
Forgetfulness for one year but still able to perform activity of daily living.
Patient Data
Global cortical atrophy (GCA) is GCA 3, where severe end stage atrophy throughout the complete cerebrum bilaterally.
Medial temporal lobe atrophy (MTA) score is MTA 3, where there are widening of both choroid fissure and widening of temporal horn of lateral ventricle. The hippocampal volume and height are slightly reduced.
Large confluent of white matter hyperintensities in bilateral cerebrum, in keeping with Fazekas scale 3. Anterior temporal lobes are not involved by the white matter hyperintensities. A few hyperintensities on T2W and FLAIR are also noted within the pons. No hot cross bun sign.
A few tiny blooming artefacts noted in bilateral thalami, right temporal lobe and posterior parts of bilateral parietal lobes, in keeping with microhemorrhages.
No restricted diffusion in DWI/ADC map to suggest acute infarction.
Strategic bilateral thalamic old lacunar infarctions noted at the medial nucleus of right thalamus and left lateral thalamus.
A small old infarction noted at the right cerebellum.
A few encephalomalacic foci seen along bilateral centrum semiovale and corona radiata in keeping with old lacunar infarcts.
No hydrocephalus. Normal variant of cavum septum pellucidum.
Diffusely widened perivascular spaces in the basal ganglia, suggestive of Etat crible.
Case Discussion
Overall MR imaging features are suggestive of vascular dementia (small vessel disease, strategic infarction at bilateral thalami- especially the right medial thalamic nucleus infarcts are highly associated with cognitive dysfunction). As the MTA score is 3 for the patient's age of 65 years old, the possibility of concurrent early Alzheimer's disease should be considered.
Proper assessment of the cognition is recommended as if only affecting the memory, it will be termed mild cognitive impairment (MCI) but if more than 2 cognitive domains, it is termed dementia.
The microhemorrhages are likely to be related with hypertension due to the bilateral thalami location. Differential includes cerebral amyloid angiopathy.
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