0:00

So, case number four is a 72-year-old

0:03

with memory loss.

0:05

They had an MRI of the brain in 2014

0:09

with quantitative volumetrics.

0:12

We look here at the DWI,

0:14

and I don't see any evidence of an acute infarct.

0:17

This is the GRE sequence,

0:19

and we see this area of prominent susceptibility

0:22

artifact here in the left frontal lobe.

0:25

So, let's take a closer look at that

0:26

on the T2-weighted image.

0:28

On the T2-weighted image,

0:29

there's central T2 hyperintensity

0:32

with that surrounding zone of old

0:34

hemosiderin staining.

0:36

On the FLAIR,

0:37

central FLAIR hyperintensity, again,

0:38

with surrounding zone of old hemosiderin staining.

0:41

This is the classic appearance

0:43

of a cavernous angioma.

0:45

On the FLAIR sequence,

0:47

we see only trace microvascular

0:48

ischemic disease.

0:49

Really not much at all.

0:51

The patient has moderate cerebral

0:53

atrophy with a biparietal predilection.

0:56

You see how prominent the sulci are

0:57

in the parietal lobes,

0:59

and really only very mild temporal lobe atrophy.

1:03

Now, in 2014,

1:05

the patient then went on to

1:06

have an FDG brain PET CT.

1:09

And this is the brain PET CT, which,

1:12

when I ran this through the MEM

1:13

neural analysis software,

1:15

it showed statistically significant

1:17

hypometabolism in the bilateral parietal lobes

1:20

and within the bilateral posterior cingulate gyri.

1:24

There was mild hypometabolism in the

1:27

bilateral temporal lobes here,

1:28

but it wasn't statistically

1:30

significant in the temporal lobes.

1:31

So you can see how useful using

1:33

something like a MEM neuroanalysis

1:35

software is, because sometimes,

1:37

with just visual inspection,

1:38

it's really hard to tell what would

1:40

have been statistically significant

1:42

compared to a normative database.

1:44

But that's what this PET showed.

1:46

The patient then returned for

1:47

an MRI of the brain in 2016.

1:50

So let's take a look at that

1:52

when we look at the study.

1:53

Here's the old study from

1:54

2014 on the left.

1:56

And here is the new study

1:58

from 2016 on the right.

2:00

We can see that there's progression

2:02

in atrophy again,

2:04

at least moderate in degree,

2:05

in the bilateral parietal lobes.

2:07

There's also some progression

2:08

in temporal lobe atrophy,

2:10

but it's still very mild in degree

2:12

in the temporal lobes,

2:13

really not too much to speak of.

2:16

And the cavernous angioma that we saw

2:18

before is really unchanged since

2:21

the prior study. Then, in 2016,

2:24

the patient also went on to

2:26

have an amyloid PET study.

2:28

And this is the amyloid study here.

2:30

And you can see it's

2:31

diffusely positive,

2:32

so binding of that amyloid tracer

2:34

throughout the cortex.

2:35

The entire brain looks dark.

2:37

This is a positive amyloid study.

2:40

The patient then returned for an MRI

2:43

of the brain two years later.

2:45

And when they returned two years

2:48

later, this is the 2018 study.

2:51

So 2018, 2016 and 2014.

2:55

And now we're finally starting

2:57

to see some significant.

3:00

Progression in atrophy in the

3:02

bilateral temporal lobes.

3:04

This is what it was on

3:05

the prior studies.

3:06

And now look at the size of the

3:07

temporal horns and the size of the

3:08

psalci at this point in time.

3:11

So this fourth case, again,

3:12

was a 72-year-old with memory loss.

3:14

There was their MRI in 2014.

3:17

Not too much in the way of atrophy

3:20

in the temporal lobes,

3:21

really only mild in degree.

3:22

A quantitative volumetric study was

3:24

done in 2014 with this MRI,

3:26

and that was totally normal that,

3:28

you see,

3:28

the hippocampal volumes are actually

3:30

above the mean for patient

3:31

age at that time.

3:33

And here are the inferior

3:34

lateral ventricles,

3:35

right exactly where they're supposed

3:36

to be. This is NeuroQuant.

3:38

This is icobrain.

3:39

These are both negative.

3:40

The patient then had the FDG

3:42

brain PET CT in 2014,

3:45

the brain PET CT showed hypometabolism

3:49

here in the bilateral temporal lobes,

3:51

but it wasn't statistically

3:53

significant.

3:54

This is the PET CT fusion.

3:56

This is the PET MR.

3:57

Fusion. And again,

3:58

you can see how helpful it is running

4:00

it through the MIM Neuroanalysis

4:01

software,

4:02

because by visual inspection alone,

4:04

I probably might have thought that

4:05

was statistically significant,

4:06

but it wasn't. However,

4:08

there was statistically significant

4:09

hypometabolism in the bilateral parietal

4:12

lobes and in the bilateral

4:13

posterior cingulate gyrus.

4:15

This is a look here at the icobrain

4:18

study in 2014, which was negative.

4:20

This again is summarizing

4:22

what we saw here,

4:23

the cavernous angioma and

4:24

the left frontal lobe.

4:26

The patient had come back in 2016.

4:29

We still didn't see a lot of atrophy

4:31

in the temporal lobes,

4:31

although a little more than before.

4:33

And they had an amyloid PET in 2016.

4:35

This is the PET CT fusion.

4:37

This is the amyloid PET MR.

4:39

Fusion. Diffusely positive.

4:41

So this patient has Alzheimer's

4:42

disease.

4:43

And then finally, we start to see some

4:45

atrophy, now moderate in degree,

4:47

in the bilateral temporal lobes when

4:49

they came back two years later.

4:51

And the reason I show this case is

4:53

to emphasize the importance of

4:55

encouraging your referrers to order

4:56

quantitative volumetric imaging every

4:59

time the patient comes back

5:00

for subsequent imaging,

5:01

because quantitative analysis is

5:04

really just a volumetric snapshot

5:06

at one point in time.

5:07

And what we want to see is that sort

5:10

of rapid drop-off in the normative

5:12

percentile if we're concerned

5:14

about Alzheimer's disease.

5:15

So it's important to keep ordering

5:17

those quant studies with

5:18

every follow-up study.