0:00

This was a 58-year-old patient who presented

0:03

with a Wallenberg syndrome.

0:06

Wallenberg syndrome typically is due to

0:09

involvement of the posterior inferior cerebellar

0:12

artery infarction of the lateral medulla.

0:15

As we scan through this patient

0:17

on the FLAIR scans,

0:18

we see indeed that the patient has an area of

0:21

hemorrhage within the posterior aspect

0:24

of the right side of the medulla,

0:27

which is verified on the T2-weighted scan.

0:29

Despite this, on the ADC map,

0:32

we're not seeing any dark signal intensity other

0:35

than the hemorrhage to suggest an acute infarction.

0:39

As we scan further superiorly,

0:42

we again see some involvement of the posterior

0:44

pontine structures, as well as white matter

0:49

disease in the periventricular and subcortical regions.

0:53

However, this patient has, again,

0:56

a pattern of involvement that is somewhat

1:00

atypical for our usual small

1:02

vessel ischemic changes,

1:04

and that is that there is the more selective

1:06

involvement of the anterior temporal lobe

1:08

seen on this axial FLAIR scan.

1:11

It is also verified on the T2-weighted scan

1:14

and on the ADC map.

1:16

So what are the unique features of this case?

1:18

We have anterior temporal lobe involvement,

1:21

which more clearly seen on the T2-weighted scan,

1:25

appears to extend all the way to the

1:27

periphery of the white matter

1:32

in this pattern that is also seen on

1:36

the ADC map as T2 shine through.

1:39

Selective anterior temporal lobe involvement

1:42

with disease could occur

1:44

in association with trauma.

1:46

And we talked about how the anterior temporal lobes

1:48

will sometimes flash forward and bang up

1:51

against the greater wing of the sphenoid in

1:53

patients who have significant head trauma,

1:56

in the trauma talk that was given previously.

1:59

However,

1:59

there is no hemorrhage involved

2:01

or hemorrhage seen here.

2:03

And this kind of fluffy involvement of the

2:05

entire white matter bilaterally

2:07

and it's fairly symmetrically,

2:08

is what we typically will

2:10

identify in patients with CADASIL.

2:13

When we suspect CADASIL,

2:14

we want to next look at whether or not there is

2:18

subcortical involvement elsewhere,

2:20

and also to look at the external capsule.

2:24

So here we are at the level of the external

2:26

capsule on the T2-weighted scan,

2:28

and we'll bring the FLAIR scan

2:29

up to that region as well.

2:31

So the external capsule is seen here in this

2:34

linear area of bilateral involvement

2:37

on both the FLAIR scan,

2:39

as well as the T2-weighted images.

2:44

So with this combination,

2:46

one would suggest that this patient has CADASIL

2:49

and had a superimposed hemorrhagic lesion

2:53

to the medulla, unrelated to the CADASIL.

2:56

CADASIL is not a hemorrhagic condition.

3:00

If we pull up the susceptibility-weighted scans,

3:04

we can see that hemorrhage within the brainstem,

3:06

the medulla, quite clearly,

3:09

and we do not see other areas other than what is

3:13

identified here in the thalamus,

3:16

as well as the basal ganglia region.

3:19

So this patient likely has hypertension and had

3:22

a hypertensive bleed into the medulla

3:25

with superimposed hemorrhages,

3:28

old in age in the deep gray matter

3:30

from hypertensive disease.

3:34

So just because you have hypertension

3:37

doesn't mean you can't have CADASIL,

3:39

and just because you have CADASIL,

3:40

doesn't mean you can't have hypertension.

3:42

So this is a case

3:45

in which there is two diseases going on,

3:47

the CADASIL, as well as hypertensive hemorrhages.