Q: What is the preferred and differential diagnosis? show answer
Cerebral amyloid angiopathy presenting with psychiatric symptoms
A 75 year old gentleman with a past medical history of hypertension presented to ED with a several day history confusion associated with auditory and visual hallucinations. He had no past psychiatric history. Delirium was considered as the first differential diagnosis, but no cause could be found on screening blood tests, urinalysis, chest x-ray or CT brain. The episode resolved spontaneously with supportive inpatient care, but a depressive episode ensued. A subsequent cognitive examination revealed impairments of both memory and executive function.
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There are innumerable high T2 whiter matter foci in both cerebral hemispheres, more confluent in the periventricular regions. There are also innumerable tiny hypointense foci scattered throughout the cerebral hemispheres and infra-tentotrial brain, suggestive of micro haemorrhages. However, no diffusion restriction is seen to suggest an acute infarct.
There is no extra-axial collection. The ventricles and sulci are normal for the patient's age. The basal cisterns are patent. Midline structures have a normal appearance.
The A1 segment of the right anterior cerebral artery is absent, with the anterior circulation supplied by the right anterior cerebral artery and anterior communicating artery. Note is also made of a prominent right posterior communicating artery supplying the right posterior cerebral artery. There is otherwise normal flow generated signal in the major intracranial arteries with no stenosis, filling defect or aneurysm greater than 3mm.
According to the Boston diagnostic criteria, the clinical and radiological evidence in this case suggests that this patient has probable cerebral amyloid antipathy.
In addition to cognitive impairment and dementia, cerebral amyloid angiopathy is not uncommonly associated with psychiatric symptoms such as personality change and depression1.