A 74-year-old woman is brought to the office by her son. He is concerned because his mother had an unprovoked fall a year ago and has since relied on him to coordinate her activities and make decisions about everyday matters. The patient's symptoms seemed to improve until she sustained another significant fall about 6 months ago. She has also become mildly forgetful, experiences occasional mood swings, and now seems sad most of the time. The patient has a long history of hypertension, stress urinary incontinence, and depression. She has a family history of colorectal cancer and Alzheimer disease. Temperature is 36.7 C (98 F), blood pressure is 141/87 mm Hg, pulse is 82/min, and respirations are 14/min. Neurologic examination shows weakness and sensory deficits on the right side. Mental status examination is significant for low volume of speech and flat affect. The remainder of the examination is within normal limits. Neuroimaging would most likely show which of the following?

Question

A 74-year-old woman is brought to the office by her son.  He is concerned because his mother had an unprovoked fall a year ago and has since relied on him to coordinate her activities and make decisions about everyday matters.  The patient's symptoms seemed to improve until she sustained another significant fall about 6 months ago.  She has also become mildly forgetful, experiences occasional mood swings, and now seems sad most of the time.  The patient has a long history of hypertension, stress urinary incontinence, and depression.  She has a family history of colorectal cancer and Alzheimer disease.  Temperature is 36.7 C (98 F), blood pressure is 141/87 mm Hg, pulse is 82/min, and respirations are 14/min.  Neurologic examination shows weakness and sensory deficits on the right side.  Mental status examination is significant for low volume of speech and flat affect.  The remainder of the examination is within normal limits.  Neuroimaging would most likely show which of the following?

Quizplus · Accepted Answer

11ec25c8_d490_a987_bc81_953e0b751900_MD0003_00 This patient's presentation is consistent with likely undiagnosed strokes and subsequent vascular dementia (VaD). She is described as having a sudden change in functional status starting a year ago after an unprovoked fall that is characterized by early problems with executive function (eg, planning activities, making decisions). She also shows a stepwise decline in functioning, entailing some improvement in symptoms but followed by another fall (possibly a repeat stroke) and subsequent problems with mood. This patient's early mild forgetfulness is also typical of VaD and can help differentiate it from the more profound memory problems seen in Alzheimer disease (AD). In addition, she has risk factors for stroke (eg, age, hypertension) and focal neurologic findings (eg, right-sided hemiparesis, sensory deficits) that are consistent with the diagnosis of VaD. Neuroimaging in patients with VaD classically demonstrates a cortical and/or subcortical infarction with or without deep white matter changes from chronic ischemia. Neuroimaging (Choice B) The neuroimaging finding of frontal and temporal lobe atrophy is typical of frontotemporal dementia, which presents with progressive personality changes such as disinhibition and compulsive behavior early in the disease. This patient has had occasional mood swings, but her stepwise decline and neurologic deficits are more consistent with VaD. (Choice C) The neuroimaging finding of medial temporal lobe atrophy is characteristic of AD, which is a slowly progressive neurodegenerative disease characterized initially by memory loss, followed by problems with language and visuospatial deficits. This patient's presentation is more consistent with VaD, given the abrupt and stepwise nature, focal neurologic findings, and mild memory problems. (Choice D) Major depression may be accompanied by or present with cognitive impairment in the elderly; it is not typically associated with any neuroimaging abnormalities. Despite her history of depression, this patient's prominent neurologic dysfunction (eg, unprovoked falls, focal neurologic deficits) and disease course are more consistent with VaD than with depression-related cognitive impairment. (Choice E) The neuroimaging finding of ventriculomegaly is characteristic of normal-pressure hydrocephalus, which initially presents with ataxia followed by dementia and urinary incontinence. This patient's focal neurologic findings are more characteristic of VaD, and her incontinence predates the onset of her cognitive and balance problems. Educational objective: Vascular dementia typically presents as a sudden or stepwise decline in executive function with mild memory loss early in the disease. Patients can have focal neurologic deficits on examination, and neuroimaging classically demonstrates a cerebral infarction and/or deep white matter changes from chronic ischemia. References: Vascular dementia. (http://www.ncbi.nlm.nih.gov/pubmed/26595643)

A 74-Year-Old Woman Is Brought to the Office by Her