Advanced Neurodegeneration in a 50-Year-Old Female: A Diagnostic Radiology Case Study

 
Advanced Neurodegeneration
 
Nicole Thomason
Date
Diagnostic Radiology (RAD 4001)
Dr. Shekhar Khanpara
 
Clinical History
 
Patient is a 50 yo F who presented to an outpatient clinic with her husband
for concerns about her memory. Her symptoms began suddenly 
a year and
a half ago 
when she lost her ability to write. At this time the patient
initially had an MRI done in Fort Worth. Since then her symptoms have
gradually progressed and now she reports
 difficulties writing, reading,
holding conversations, recall, maintaining concentration as well as
memory loss, getting lost in familiar places
, and an inability to balance her
checkbook. Some of her 
ADLs have also been affected 
and she has
experienced worsening anxiety.
Denies tremors, falls, difficulty walking, incontinence, changes in weight,
strokes, sleep changes, changes in temper, changes in personality,
hallucinations
 
Clinical History
 
Physical Exam: 
Mental status exam revealed that patient is
oriented to person but not place or time
. She has 
impaired
memory and calculation abilities.
 No dysphasia/aphasia.
The remainder of the physical exam (including a full neuro
exam) revealed no abnormalities.
PMH: 
Hypertension controlled with medications, undefined
thyroid nodules, anxiety/depression
FAM HX: 
No fam hx of memory issues.
SOCIAL HX: 
Drinks a small amount of alcohol 1x per month
 
Clinical History
 
Previous imaging at the initial onset of symptoms (1.5yrs ago) showed
only:
Mild generalized changes advanced for the patient's given age.
 No
disproportionate atrophy. Subtle foci of T2/FLAIR hyperintensity within the
periventricular white matter bilaterally (nonspecific finding that can be seen
in patients with migraine headaches or as the sequela of chronic small vessel
ischemia); were not able to acquire actual images
Steps after Clinic visit:
Ordered: 
FDG PET Scan
Bloodwork (CBC, CMP, FBS, Lipids, HgbA1c, TFT, Thiamine, Vitamin B12,
Folate, CK, ESR, RPR, Apo E. Include PS1, PS2, and APP mutation analyses, FTD
genetic analyses, and the NMDA-R antibody)
Started on donepezil and escitalopram
 
Relevant Imaging
 
PET CT (01/08/21)
 
Relevant Imaging
 
PET CT (01/08/21)
 
More relevant imaging
 
CT/PET Findings
Mild cerebral atrophy on corresponding CT Images
Marked 
symmetrical hypometabolism 
within bilateral 
parietal
 and middle
and posterior 
temporal lobes
Areas of
 hypometabolism 
are also seen within bilateral 
anterior frontal lobes
Symmetrical FDG uptake is seen within bilateral occipital lobes, posterior
frontal lobes, and basal ganglia
Findings suggestive of advanced neurodegenerative disorder, mixed with
the Alzheimer’s disease and the frontal temporal dementia
Highlight and summarize key imaging findings
 
Alzheimer’s Disease
Bilateral, symmetric hypometabolism 
in the  
temporoparietal
, precuneus
and posterior cingulate areas
The anterior cingulate, visual cortex, basal ganglia, thalami, occipital lobes,
and cerebellum are usually spared
 
Highlight and summarize key imaging findings
 
Frontotemporal Dementia
frontal and temporal lobes
 are predominantly affected, depending on the
genetic and clinical phenotype, individuals demonstrate very variable regional
atrophy.
Can be asymmetric
 
 
 
Differential Diagnosis
 
Alzheimers Disease
Sx’s: memory concerns, a change in writing, a change in multi-tasking, concentrating
issues, etc.
Imaging: Bilateral, symmetric hypometabolism in the  temporoparietal lobes
Frontotemporal Dementia
Sx’s: concentration/executive issues
Imaging: bilateral anterior frontal lobe hypometabolism; temporal lobe
hypometabolism
Vascular Dementia:
Sx’s: wide variety of neurocognitive symptoms
Imaging: Better imaged on CT/MRI than PET scan but with no evidence on previous
MRI
 
Discussion
 
Working diagnosis of “Advanced Neurodegeneration”
DIFFUSE decrease in uptake on PET scan can explain symptoms but does not
perfectly fit a diagnosis in this patient
Characteristics of both Frontotemporal Dementia and Alzheimer’s Disease
Further work up:
Bloodwork: CBC, CMP, FBS, Lipids, HgbA1c, TFT, Thiamine, Vitamin B12,
Folate, CK, ESR, RPR, Apo E. Include PS1, PS2, and APP mutation analyses, FTD
genetic analyses, and the NMDA-R antibody.
Meds: start donepezil 5 mg po qAM today and go to 10 in 1 month.
EEG
Final Diagnosis
 
Working diagnosis of “Advanced Neurodegeneration”
 
ACR appropriateness Criteria
 
ACR appropriateness Criteria
 
Cost of PET-CT:
https://www.newchoicehealth.com/places/texas/houston
$1500 - $4000
 
ACR appropriateness Criteria
 
Hypometabolism
 on FDG-PET is thought to be related to decreased
synaptic activity and is 
a biomarker of neurodegeneration
 or neuronal
injury.
CMS has made FDG-PET available to Medicare recipients to assist with the
diagnosis of dementia in the appropriate clinical setting (eg, to distinguish
AD from FTD) in recognition of this usefulness.
FDG-PET is an established tool for differentiating FTD and AD and
classifying different FTD subtypes.
CMS coverage for payment for FDG-PET brain to differentiate AD and FTD
in patients with documented cognitive decline of at least 6 months and a
recently established diagnosis of dementia.
Take Home Points / Teaching points
 
FDG-PET is an imaging study that can give
an idea of metabolic rates in certain
areas
FDG-PET can differentiate types of
dementia that are hard to differentiate
clinically or with CT/MRI
Alzheimers Disease will show bilateral,
symmetric hypometabolism in the
temporoparietal lobes
Frontotemporal Dementia will show
anterior frontal lobe and temporal lobe
hypometabolism and can be asymmetric
References
 
Images:
https://media.sciencephoto.com/image/m1400034/800wm
https://radiopaedia.org/cases/brain-lobes-annotated-mri-1
https://radiologykey.com/wp-
content/uploads/2016/09/A308863_1_En_15_Fig4_HTML.jpg
 
ACR Appropriateness Criteria
https://acsearch.acr.org/docs/3111292/Narrative/
 
 
Slide Note
Embed
Share

Patient Nicole Thomason, a 50-year-old female, presented with memory concerns and progressive cognitive decline. Initial imaging showed subtle changes, while recent PET CT revealed marked hypometabolism in specific brain regions indicative of advanced neurodegenerative disorder, potentially Alzheimer's disease and frontal temporal dementia. Treatment includes donepezil and escitalopram.


Uploaded on Jul 15, 2024 | 0 Views


Download Presentation

Please find below an Image/Link to download the presentation.

The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.

E N D

Presentation Transcript


  1. Advanced Neurodegeneration Nicole Thomason Date Diagnostic Radiology (RAD 4001) Dr. Shekhar Khanpara

  2. Clinical History Patient is a 50 yo F who presented to an outpatient clinic with her husband for concerns about her memory. Her symptoms began suddenly a year and a half ago when she lost her ability to write. At this time the patient initially had an MRI done in Fort Worth. Since then her symptoms have gradually progressed and now she reports difficulties writing, reading, holding conversations, recall, maintaining concentration as well as memory loss, getting lost in familiar places, and an inability to balance her checkbook. Some of her ADLs have also been affected and she has experienced worsening anxiety. Denies tremors, falls, difficulty walking, incontinence, changes in weight, strokes, sleep changes, changes in temper, changes in personality, hallucinations

  3. Clinical History Physical Exam: Mental status exam revealed that patient is oriented to person but not place or time. She has impaired memory and calculation abilities. No dysphasia/aphasia. The remainder of the physical exam (including a full neuro exam) revealed no abnormalities. PMH: Hypertension controlled with medications, undefined thyroid nodules, anxiety/depression FAM HX: No fam hx of memory issues. SOCIAL HX: Drinks a small amount of alcohol 1x per month

  4. Clinical History Previous imaging at the initial onset of symptoms (1.5yrs ago) showed only: Mild generalized changes advanced for the patient's given age. No disproportionate atrophy. Subtle foci of T2/FLAIR hyperintensity within the periventricular white matter bilaterally (nonspecific finding that can be seen in patients with migraine headaches or as the sequela of chronic small vessel ischemia); were not able to acquire actual images Steps after Clinic visit: Ordered: FDG PET Scan Bloodwork (CBC, CMP, FBS, Lipids, HgbA1c, TFT, Thiamine, Vitamin B12, Folate, CK, ESR, RPR, Apo E. Include PS1, PS2, and APP mutation analyses, FTD genetic analyses, and the NMDA-R antibody) Started on donepezil and escitalopram

  5. Relevant Imaging PET CT (01/08/21)

  6. Relevant Imaging PET CT (01/08/21)

  7. More relevant imaging CT/PET Findings Mild cerebral atrophy on corresponding CT Images Marked symmetrical hypometabolism within bilateral parietal and middle and posterior temporal lobes Areas of hypometabolism are also seen within bilateral anterior frontal lobes Symmetrical FDG uptake is seen within bilateral occipital lobes, posterior frontal lobes, and basal ganglia Findings suggestive of advanced neurodegenerative disorder, mixed with the Alzheimer s disease and the frontal temporal dementia

  8. Highlight and summarize key imaging findings Alzheimer s Disease Bilateral, symmetric hypometabolism in the temporoparietal, precuneus and posterior cingulate areas The anterior cingulate, visual cortex, basal ganglia, thalami, occipital lobes, and cerebellum are usually spared

  9. Highlight and summarize key imaging findings Frontotemporal Dementia frontal and temporal lobes are predominantly affected, depending on the genetic and clinical phenotype, individuals demonstrate very variable regional atrophy. Can be asymmetric

  10. Differential Diagnosis Alzheimers Disease Sx s: memory concerns, a change in writing, a change in multi-tasking, concentrating issues, etc. Imaging: Bilateral, symmetric hypometabolism in the temporoparietal lobes Frontotemporal Dementia Sx s: concentration/executive issues Imaging: bilateral anterior frontal lobe hypometabolism; temporal lobe hypometabolism Vascular Dementia: Sx s: wide variety of neurocognitive symptoms Imaging: Better imaged on CT/MRI than PET scan but with no evidence on previous MRI

  11. Discussion Working diagnosis of Advanced Neurodegeneration DIFFUSE decrease in uptake on PET scan can explain symptoms but does not perfectly fit a diagnosis in this patient Characteristics of both Frontotemporal Dementia and Alzheimer s Disease Further work up: Bloodwork: CBC, CMP, FBS, Lipids, HgbA1c, TFT, Thiamine, Vitamin B12, Folate, CK, ESR, RPR, Apo E. Include PS1, PS2, and APP mutation analyses, FTD genetic analyses, and the NMDA-R antibody. Meds: start donepezil 5 mg po qAM today and go to 10 in 1 month. EEG

  12. Final Diagnosis Working diagnosis of Advanced Neurodegeneration

  13. ACR appropriateness Criteria

  14. ACR appropriateness Criteria Cost of PET-CT: https://www.newchoicehealth.com/places/texas/houston $1500 - $4000

  15. ACR appropriateness Criteria Hypometabolism on FDG-PET is thought to be related to decreased synaptic activity and is a biomarker of neurodegeneration or neuronal injury. CMS has made FDG-PET available to Medicare recipients to assist with the diagnosis of dementia in the appropriate clinical setting (eg, to distinguish AD from FTD) in recognition of this usefulness. FDG-PET is an established tool for differentiating FTD and AD and classifying different FTD subtypes. CMS coverage for payment for FDG-PET brain to differentiate AD and FTD in patients with documented cognitive decline of at least 6 months and a recently established diagnosis of dementia.

  16. Take Home Points / Teaching points FDG-PET is an imaging study that can give an idea of metabolic rates in certain areas FDG-PET can differentiate types of dementia that are hard to differentiate clinically or with CT/MRI Alzheimers Disease will show bilateral, symmetric hypometabolism in the temporoparietal lobes Frontotemporal Dementia will show anterior frontal lobe and temporal lobe hypometabolism and can be asymmetric

  17. References Images: https://media.sciencephoto.com/image/m1400034/800wm https://radiopaedia.org/cases/brain-lobes-annotated-mri-1 https://radiologykey.com/wp- content/uploads/2016/09/A308863_1_En_15_Fig4_HTML.jpg ACR Appropriateness Criteria https://acsearch.acr.org/docs/3111292/Narrative/

Related


More Related Content

giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#