0:00

Okay.

0:01

So this first case is a 79-year-old

0:03

with memory loss.

0:05

We're looking here at an MRI of the brain in 2013.

0:10

This is the DWI sequence, the GRE sequence,

0:14

the T2 sequence, and the FLAIR sequence.

0:16

Everyone has their own pattern

0:18

in how they read studies.

0:19

I tend to always look at the

0:21

DWI and the GRE first,

0:23

just because you don't want to use the DWI to

0:25

detect acute strokes, and you don't want to miss

0:27

that. In the GRE, we use to look for hemosiderin,

0:31

staining for blood products,

0:32

and also you don't want to miss a bleed.

0:34

So I tend to start with those.

0:35

You see, the DWI here is negative.

0:38

There's no evidence of acute infarct.

0:40

The GRE actually, in the GRE.

0:42

This is a subtle finding on this

0:44

initial MRI from 2013,

0:47

but there's a little focus of hemosiderin

0:50

staining, old hemosiderin staining, by the way,

0:52

on GRE susceptibility,

0:54

weighted infarct can be hemosiderin

0:55

staining or calcification,

0:57

although hemosiderin staining is much more common

1:00

scenario, unless you're in the basal ganglia.

1:02

So there's a little punctate focus there.

1:04

You see here along the lateral margin of the

1:07

right pontomesencephalic junction,

1:09

there's another punctate focus here.

1:11

There's another little focus here in the region

1:14

of the internal capsule on the right.

1:17

If we look here at the FLAIR sequence,

1:20

we see mild to moderate microvascular

1:23

ischemic disease, little foci here,

1:25

scattered throughout the cerebral white matter.

1:27

Here's one in the right temporal subcortical white

1:30

matter. And then if you look here at the T2,

1:34

we see moderate cerebral atrophy with

1:37

mesiotemporal and biparietal predilection.

1:39

So you see here the temporal horns

1:41

are kind of prominent,

1:42

the psilsi are prominent in the temporal lobes.

1:44

And again,

1:45

SoCal prominence here in the bilateral parietal

1:49

lobes. Now let's take a look at the MRI from 2016,

1:53

and we will compare it to the MRI of 2013.

2:00

This is the T2-weighted sequence from 2016.

2:03

And you can see here this sort of significant

2:07

progression in cerebral atrophy.

2:09

We now have moderately severe cerebral atrophy

2:12

in the bilateral temporal lobes.

2:14

So there's a strong temporal predilection.

2:16

Look at the size of the temporal horns

2:18

here compared to the prior study.

2:20

The parietal sulci are also larger in size.

2:24

We'll compare here the FLAIR sequence.

2:28

Here's the FLAIR sequence from 2016.

2:30

And here is the FLAIR sequence from

2:35

the earlier study in 2013.

2:38

Microvascular ischemic disease has

2:41

progressed since the prior study.

2:43

Multiple new foci are now seen.

2:45

So that has progressed.

2:47

And now let's take a look at the GRE.

2:51

On the left, I'm going to load the 2003 study,

2:54

and then on the right-hand side,

2:57

I will load the 2016.

2:59

Study.

3:01

Here we go.

3:03

And now what you can see is there's multiple new

3:06

foci of hemosiderin staining scattered

3:10

throughout the brain.

3:11

So here's one in the right temporal lobe.

3:14

Here's another one in the left frontal lobe,

3:16

at the gray-white junction.

3:17

This wasn't present before, this was present,

3:19

but is now more conspicuous.

3:21

Here's a little punctate,

3:22

one that wasn't present before,

3:24

along the ependymal margin of the left lateral

3:26

ventricle. Here's another one here.

3:28

That's in the presential gyrus

3:30

of the left frontal lobe.

3:31

Here's another one here in the

3:33

left superior frontal gyrus.

3:35

These are often located at

3:36

the gray-white junctions.

3:38

And then you can see how much more conspicuous

3:40

this one is here at the junction of the pons

3:42

in the middle cerebral peduncles.

3:44

Here's another one here in the high pons.

3:46

We've got a couple here in the

3:48

right cerebellar hemisphere.

3:49

So this patient has cerebral amyloid angiopathy

3:52

that has significantly progressed

3:54

since the prior study.

3:55

And this has all really happened over the past

3:57

three years. Now, let's take a look.

4:00

The patient then also had an amyloid PET in 2016.

4:04

Here's the amyloid I'm going to invert,

4:06

because this is how we view these.

4:08

So this is the gray scale, and you see diffuse

4:11

binding of that tracer throughout the cortex.

4:15

This is a positive amyloid study,

4:18

which indicates that this patient

4:20

really has Alzheimer's disease.

4:23

So this is again the 79-year-old with memory loss.

4:26

We see here the MRI in 2013,

4:30

where we had moderate cerebral atrophy

4:31

with a right temporal predilection,

4:33

and the patient had NeuroQuant at that time.

4:37

And the NeuroQuant study did show

4:39

some hippocampal volume loss.

4:41

It also showed statistically significant

4:43

enlargement of the inferior lateral ventricles.

4:46

And then, in 2016, the patient came back.

4:50

At this point,

4:51

we have moderately severe bilateral temporal

4:53

lobe volume loss, right, greater than left,

4:56

and we see some rapid decline of the volumetric

4:59

values off the normative curve.

5:01

This is a heat map overlay here.

5:04

This happens to be NeuroQuant.

5:06

This is IcoBrain on the same patient.

5:08

Here's a closer look at the NeuroQuant study.

5:11

You can see the values of the hippocampus in 2013

5:14

and how rapidly they've dropped off in 2016.

5:18

So, as any person ages,

5:21

they will get some hippocampal

5:22

volume loss over time.

5:24

But it tends to move very slowly when

5:26

you see a rapid decline here,

5:28

that's a big red flag for Alzheimer's disease

5:31

or some other dementia syndrome.

5:33

This is the hippocampal occupancy score.

5:35

And this has dramatically decreased over time.

5:38

And then here's the inferior lateral ventricles.

5:40

You see where it went from 2013 to 2016.

5:44

This is the IcoBrain report.

5:46

In 2013,

5:47

we had statistical significance less than one

5:50

percentile on the normative

5:52

percentile curve in 2013.

5:53

And now the hippocampal volumes have dropped in

5:56

And now we are getting statistical.

5:59

Significance throughout the entire temporal

6:01

cortex in the 2016 study.

6:04

This is that Bullseye graph I mentioned

6:06

for the IcoBrain report,

6:07

where the points point towards areas of statistical

6:10

significance. This blue zone, as you remember,

6:13

is in the one percentile.

6:15

Temporal cortex here is now statistically

6:17

significant. The white dotted line, by the way,

6:19

is the prior study, and the black

6:21

is the current study.

6:22

This is the segmentation where you see what the

6:25

hippocampi looked like here in orange in 2013,

6:28

and how they have become progressively atrophic

6:32

by the 2016 study. This is a heat map overlay.

6:36

NeuroQuant offers this.

6:37

Anything that's red is increasing in size,

6:40

so the ventricles and the psalci are increasing

6:43

in size since the prior time point.

6:45

This is an overlay of the current study with the

6:48

prior, and the blue is anything that's decreasing.

6:51

So you can see here that the cortex is decreasing

6:54

in volume since the prior exam.

6:57

Again, as a review from what we saw,

6:59

this patient has cerebral amyloid angiopathy with

7:02

multiple little foci of hemosiderin staining,

7:04

which had significantly progressed

7:06

over three years.

7:07

And the patient had an amyloid PET CT study

7:09

in 2016, which was diffusely positive.

7:13

So this patient has both Alzheimer's disease

7:15

and cerebral amyloid angiopathy.