0:00

This is a 56-year-old man with proven classic PD,

0:05

although it didn't start out that way.

0:07

It started out with him complaining of

0:09

gastrointestinal discomfort for over 15 months.

0:14

You might think PD, gastrointestinal discomfort.

0:19

Well, one of the hallmark features of Parkinson's disease

0:23

is diminished autonomic function.

0:25

So, I've seen patients present

0:26

with postural hypotension.

0:28

I've seen patients present with a volvulus,

0:31

a sequel volvulus from loss of

0:33

contraction of the colon.

0:34

And I've seen people present with bacterial

0:37

overgrowth due to loss of contraction of the colon.

0:40

So decreased colonic inertia,

0:42

which was this patient's initial symptom,

0:45

which led to a brain MRI.

0:47

He had a father that died of

0:50

multi-infarct disease.

0:52

And so when we looked at his FLAIR image

0:55

and saw all these innumerable white

0:57

spots in a 56-year-old,

0:59

we thought that perhaps a vascular etiology

1:03

was his underlying problem.

1:05

And he was placed on aggressive medication to

1:09

lower his elevated cholesterol

1:12

and bring his LDL below 100,

1:14

which would be the typical hallmark therapy.

1:17

I allow, whether there's cognitive decline or not,

1:20

I allow one gliotic area per decade.

1:23

So if you're 60, I'll allow six.

1:25

Now, a lot of this is dependent upon your culture.

1:28

In Japan,

1:29

where they eat a lot of fish and drink a lot of

1:31

tea and have other habits that are

1:34

somewhat more healthy than ours,

1:36

they have a much lower incidence of gliotic

1:38

spots per decade than we do.

1:40

But this gentleman has way too many.

1:42

He has almost a hundred of them.

1:45

But that wouldn't explain the symptoms

1:49

which were overlooked for so long,

1:51

diminished colonic inertia,

1:53

and then on physical examination by a very

1:55

sharp clinician, rigidity was detected,

1:59

along with decrease in facial muscular tone.

2:03

So this is an individual that has had Parkinson's

2:07

symptoms for almost 24 months

2:10

at the time of this MR examination.

2:13

We've got an axial T2 on the left,

2:16

a FLAIR in the middle,

2:18

and a portion of an echo-planar study,

2:21

which is susceptibility sensitive and shows you

2:25

the substantia nigra

2:27

and the red nucleus to advantage.

2:30

Now, even though we do see a brighter compacta zone

2:34

between the substantia nigra

2:36

and the nucleus ruber,

2:38

and perhaps they're a little close together here.

2:41

Remember, he's very early on in his disease,

2:44

but what we do see is look at how blunted the

2:47

substantia nigra is on the FLAIR

2:49

and on the susceptibility-sensitive

2:52

echo-planar image.

2:53

It just comes to a screeching halt,

2:56

and we've completely lost the

2:58

little wispy, lateral swallowtail component

3:01

along the lateral aspect of the substantia nigra.

3:04

So, loss of the swallowtail sign was an event

3:09

or a demonstration of Parkinson's

3:12

on an MRI in this patient.

3:15

Patient did not have any symptoms of dementia, whatsoever.

3:19

And unlike comparison cases,

3:21

which you'll find in our series on MRI online,

3:24

look at the robust appearance of his temporal lobe.

3:27

His superior temporal lobe looks absolutely terrific.

3:31

It's robust,

3:32

which is what you would expect

3:34

in somebody with early PD.

3:35

So, if they have symptoms for two or three

3:38

or four years,

3:39

and you see loss of the anterior two thirds

3:42

of the superior temporal gyrus,

3:44

odds are you're dealing with another disease process

3:47

such as Lewy Body Dementia or LBD.

3:50

A tip off to that diagnosis.

3:53

Let's move on, shall we?