0:00

So case number two is an 86-year-old

0:03

with memory loss.

0:04

They had an MRI of the brain in 2019,

0:08

which we're looking at here.

0:09

Again, I like to start with the DWI.

0:11

You see the DWI's negatives or no acute infarcts.

0:15

When we look here at the GRE sequence,

0:17

the only thing I see here

0:18

is there's some very faint GRE

0:20

susceptibility artifact here in the left frontal lobe.

0:24

This happens to be if we look

0:25

at the post-contrast image,

0:27

that is right around a large developmental

0:30

venous anomaly.

0:30

So we see that typical Caput Medusae-type appearance

0:34

of a developmental venous anomaly.

0:36

You know, typically,

0:36

DVAs are incidental findings,

0:38

unless they're associated with a cavernous angioma,

0:41

because the cavernous angiomas can bleed.

0:43

In this particular case, though,

0:44

it's slightly unusual because the

0:47

DVA is associated with a small,

0:49

little area of encephalomalacia that you can see here.

0:52

You typically don't see that with a DVA,

0:54

but here's a little brain tissue loss here.

0:58

And again,

0:58

we have a little susceptibility artifact there.

1:01

That's really the only thing that enhances

1:03

on the post-contrast series.

1:06

If you look here in the coronal plane,

1:08

this is, again, that large DVA.

1:11

That's what that looks like.

1:13

Let's look at the T2-weighted sequence,

1:16

and I'll pull back up the FLAIR here.

1:19

So on the FLAIR,

1:20

we see all this area of patchy FLAIR hyperintensity

1:24

throughout the brain.

1:26

This patient has moderately severe,

1:28

that tells us this patient has moderately severe

1:29

baseline microvascular ischemic disease.

1:32

They also have old lacuna.

1:33

Here's an old lacuna in the right hemipons.

1:36

So, there's fairly significant

1:38

microvascular ischemic change here.

1:39

If we look at the T2-weighted sequence,

1:43

which is a sequence I like to use to assess for atrophy,

1:46

we see there's mild to moderate cerebral atrophy with a

1:49

right mesial temporal and also a

1:52

biparietal predilection here.

1:55

The only other thing that we...

1:57

just little incidental finding that we have,

2:00

there's a little bony exostosis.

2:02

I'll show you that.

2:04

And the only reason I mentioned this is because it can

2:08

be confused if it's calcified potentially

2:11

for a little meningioma.

2:13

Here it is here along the left frontal convexity,

2:16

and here it is on the post-contrast sequences.

2:19

But we see that it's actually high in signal on T1,

2:22

so it's more likely to be just a bony exostosis

2:24

rather than a tiny meningioma.

2:26

There's no definite convincing enhancement on

2:28

the surface of this.

2:30

So, let's move now.

2:31

In 2009,

2:33

the patient then went on to have an FDG brain PET CT.

2:37

Here's the FDG brain PET CT.

2:39

I'm going to invert here.

2:40

And this demonstrated statistically significant cortical

2:44

hypometabolism in the right temporal lobe.

2:48

Here.

2:48

And also in the right posterior cingulate gyrus,

2:52

we also had, statistically significant,

2:55

hypometabolism in the left frontal lobe,

2:57

but nothing in the right frontal lobe,

2:59

and it's really only in the medial

3:00

aspect of the left frontal lobe.

3:02

So, interestingly,

3:03

this is where we had that big DVA

3:06

with the little area of encephalomalacia.

3:09

But it's not really looking like an FDG type pattern.

3:12

You know,

3:12

the right frontal lobe is completely normal.

3:15

This really appears to be related to the inflammatory

3:19

response around that DVA,

3:21

which is, again, quite unusual.

3:23

But that happens to be what we see in this case.

3:26

And then,

3:26

if we look at the patient then came back for

3:28

an MRI in 2016.

3:31

So, I'll pull up some images here.

3:34

So, the images on the right here are 2016.

3:38

I'll pull up comparison images from

3:41

2009 on the left-hand side.

3:45

Okay.

3:46

And what we see here is dramatic interval progression

3:50

in the amount of cerebral atrophy

3:51

with a temporal predilection.

3:53

So now, we have moderately severe to severe atrophy

3:57

in the bilateral temporal lobes.

3:59

Again, right more than left.

4:02

So it's kind of moderately severe in the left,

4:04

moderately severe to severe in the right temporal lobe,

4:06

and moderate to moderately severe

4:08

in the bilateral parietal lobes.

4:10

That represents a significant progression

4:12

from the 2009 study.

4:14

Microvascular ischemic disease

4:16

has also significantly progressed.

4:18

It's now relatively severe in degree.

4:21

We also have multiple new...

4:23

Well, they're not new infarcts,

4:25

but they are new since the prior exam,

4:27

so they weren't present on the prior.

4:29

If we look here in the left thalamus,

4:31

we also have one here in the right caudate nucleus.

4:35

We have new ones here,

4:37

new one here in the left pons.

4:39

The one in the right hemipons was present on the prior,

4:41

but the microvascular ischemic change in old infarcts

4:46

has definitely progressed since the prior study.

4:49

So case two, again, was the 86-year-old

4:52

with memory loss.

4:53

Here's their MRI in 2009,

4:56

where we have some atrophy with a right temporal

4:58

predilection, mild to moderate in degree.

5:01

The patient also then went on to have

5:04

an FDG brain PET CT in 2009.

5:07

Again,

5:07

I run all of these PETs through the

5:09

neuroanalysis software,

5:11

which indicated that there was statistically significant

5:15

hypometabolism in the right temporal lobe.

5:17

You actually see hypometabolism in

5:19

the bilateral temporal lobes,

5:20

but it was statistically significant on the right side.

5:23

By the way, this is the FDG PET CT,

5:26

and this is the PET MR fusion.

5:28

You can clearly see some hypometabolism

5:30

here in those temporal lobes.

5:32

There was also hypometabolism again in the right

5:34

posterior cingulate gyrus,

5:35

and then in the left frontal lobe,

5:37

from that DVA.

5:38

The patient then came back in 2016.

5:41

And now, we have pretty severe atrophy in the bilateral

5:45

temporal lobes, right greater than left,

5:47

and quantitative volumetric imaging

5:49

was also done in 2016.

5:51

Here's NeuroQuant and icobrain.

5:53

And we have statistically significant reduction in

5:56

the volume of the hippocampal occupancy score

5:59

and the hippocampus,

6:01

as well as statistically significant enlargement

6:03

of the inferior lateral ventricles.

6:05

And those same things are also demonstrated

6:07

here on the icobrain report.

6:09

This is, again, a closer look at the NeuroQuant.

6:12

Here's the plot graph here showing

6:14

statistical significance.

6:15

We're down at 1% for the hippocampus and

6:18

99% elevated for that inferior

6:21

lateral ventricular volume.

6:23

And you might be wondering what the

6:24

hippocampal occupancy score is.

6:26

This is just an estimate of the

6:28

degree of hippocampal atrophy.

6:29

So, it's just the left hippocampal volume divided by

6:32

the left hippocampal volume,

6:33

plus inferior lateral ventricular volume.

6:35

Plus, on the right side,

6:37

those same value,

6:39

the same thing on the right side,

6:40

then they're average and normalized.

6:41

So, the lower hoc scores are highly associated with

6:45

progression from mild cognitive impairment

6:47

to Alzheimer's disease.

6:49

So the bottom line, really,

6:50

the only thing you need to remember is that the lower

6:52

hoc is the more at risk the patient is for developing

6:56

Alzheimer's disease.

6:57

And again, that hoc is...

6:59

we saw that on the quantitative volumetric report.

7:02

This is just the triage brain report in 2016,

7:06

and we're looking for overall patterns.

7:08

In the overall pattern here in the temporal lobe,

7:11

we see a lot of red boxes here in the temporal lobe.

7:15

This was the icobrain report from this patient.

7:17

By 2016, really,

7:19

there was statistical significance in every lobe

7:22

of the brain, including in the hippocampi,

7:24

all less than 1%.

7:26

There's a second page of the icobrain report.

7:28

Again, the whole brain volume is down now at less than 1%.

7:32

The other summary images that we had already reviewed,

7:35

the large DVA,

7:36

the little area of encephalomalacia here,

7:38

minor hemosiderin staining associated with that.

7:43

Here's that DVA again.

7:44

And here's some of the hypometabolism that

7:46

we saw in the left frontal lobe.

7:48

The patient then went on to have an amyloid PET in 2016,

7:51

and that was positive.

7:52

Here's the grayscale,

7:53

diffuse binding of the amyloid tracer to the cortex.

7:56

Same thing we see here on the color fusion.