Q: What is the preferred and differential diagnosis? show answer
Q: How might imaging investigations be helpful? show answer
A 55 year old woman with obesity, type II diabetes mellitus and poorly controlled hypertension presents with symptoms of depression and psychosis contextualised by a gradual decline in cognitive and occupational function. She does not have a significant past psychiatric history.
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There is diffuse extensive periventricular deep white matter T2 hyperintensity changes, with associated ex vacuo ventriculomegaly and global, symmetrical, supra and infratentorial involutional changes.
Multiple punctate focus of susceptibility signal loss within the cerebellar hemispheres, pons, thalami and basal ganglia. No regions of restricted diffusion.
No intra or extra-axial collections.
Extensive diffuse periventricular white matter change can be attributed to background small vessel ischaemic disease, the extent of the changes are disproportionate to the patient's age. Numerous microhaemorrhages are in a distribution suggestive of chronic hypertensive encephalopathy (hypertensive microangiopathy) .
This distribution of microhaemorrhages is typical of hypertensive encephalopathy and the location mirrors that of larger hypertensive haemorrhages which are most common in the basal ganglia, pons and cerebellar hemispheres.
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