A 65-year-old woman is brought to the office by her daughter due to forgetfulness and bizarre behavior. She recently began living with her daughter, who has noticed that the patient frequently misplaces items, forgets the purpose of an errand, and asks the same questions repeatedly. The patient had a left anterior cerebral artery embolic stroke 4 months ago. Her right leg weakness has slightly improved with physical rehabilitation at a nursing facility, but she still has to use a walker for ambulation. Her daughter states that prior to the stroke, the patient was living on her own and was "very social, outgoing, and full of life." Now, she is completely withdrawn and has no interest in day-to-day activities. She has also become suspicious of her daughter and is hoarding things. Other medical history includes hypertension and atrial fibrillation. On physical examination, the patient has a flat affect, normal speech, and right lower extremity weakness. Mental status examination shows short-term memory loss. Mini-Mental State Examination score is 22/30 and Clock-Drawing reveals executive cognitive dysfunction. Which of the following is the most likely cause of this patient's memory impairment?

Question

A 65-year-old woman is brought to the office by her daughter due to forgetfulness and bizarre behavior.  She recently began living with her daughter, who has noticed that the patient frequently misplaces items, forgets the purpose of an errand, and asks the same questions repeatedly.  The patient had a left anterior cerebral artery embolic stroke 4 months ago.  Her right leg weakness has slightly improved with physical rehabilitation at a nursing facility, but she still has to use a walker for ambulation.  Her daughter states that prior to the stroke, the patient was living on her own and was "very social, outgoing, and full of life."  Now, she is completely withdrawn and has no interest in day-to-day activities.  She has also become suspicious of her daughter and is hoarding things.  Other medical history includes hypertension and atrial fibrillation.  On physical examination, the patient has a flat affect, normal speech, and right lower extremity weakness.  Mental status examination shows short-term memory loss.  Mini-Mental State Examination score is 22/30 and Clock-Drawing reveals executive cognitive dysfunction.  Which of the following is the most likely cause of this patient's memory impairment?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d583_bca5_bc81_ef6a55866e98_MD0003_00 This patient's rapid development of memory loss, executive dysfunction, and behavioral changes 4 months following a stroke is most consistent with vascular dementia (VaD). VaD, the second-most common form of dementia after Alzheimer disease, may occur as a result of: Single, strategic infarction: One infarction may be enough to cause poststroke vascular cognitive impairment if it affects key brain areas (ie, frontal lobes, thalamus). Multiple infarctions: Multi-infarct dementia occurs when small infarcts combine to cause enough cumulative damage to the brain, resulting in noticeable cognitive deficits. Patients may not have a history of overt stroke but rather have a stepwise decline in cognitive function. In this patient, a single, left anterior cerebral artery infarction has resulted in damage to the frontal lobe, which has caused memory impairment, executive dysfunction, and marked changes in her mood and personality (eg, apathy, paranoia, social withdrawal). Patients with VaD associated with strategic infarction (eg, medial frontal lobes, medial temporal lobes, thalamus) typically experience an abrupt decline in functioning, as seen in this patient (eg, she was living independently, socially active, and "full of life" prior to the stroke). In contrast, patients with Alzheimer disease typically experience insidious onset of memory impairment over many months to years with personality and behavioral changes occurring relatively later in the disease course (Choice B). (Choice A) Although a stroke is a significant life stressor that can cause behavioral symptoms consistent with an adjustment disorder, adjustment disorder would not adequately explain this patient's memory loss, executive dysfunction, and personality change. (Choice C) Even though frontotemporal dementia (FTD) presents with early behavioral/personality changes (eg, apathy, disinhibition, hyperorality, compulsive behavior), memory impairment occurs later. FTD is due to frontotemporal neurodegeneration rather than infarction. (Choice D) There is an increased risk of depression in patients who sustain strokes. Although this can result in mild cognitive impairment, this patient is experiencing apathy rather than sadness that typically accompanies depression. In addition, this patient has a history of an anterior cerebral artery infarction, which is known to affect the frontal lobe, making VaD a more likely diagnosis. Educational objective: A single cerebral infarct may lead to vascular dementia (VaD) if it damages key areas involved in cognition (eg, medial frontal lobes, medial temporal lobes, thalamus). Patients with VaD due to a strategic infarction typically experience an abrupt decline in cognitive functioning. References: Clinical presentations and epidemiology of vascular dementia. (http://www.ncbi.nlm.nih.gov/pubmed/28515342) Pathogenesis and treatment of vascular cognitive impairment. (http://www.ncbi.nlm.nih.gov/pubmed/25531689)

A 65-Year-Old Woman Is Brought to the Office by Her