Medial temporal lobe atrophy

Case contributed by Dr Bruno Di Muzio

Presentation

Progressive cognitive decline.

Patient Data

Age: 59-year-old
Gender: Female
MRI

MRI Brain

Non specific high T2 signal foci are noted in the white matter slightly more than expected for age and likely due to chronic small vessel ischaemia, but probably insufficient to explain cognitive decline. The left hippocampal formation is mildly decreased in size. The temporal horn of the lateral ventricle on this side is not particularly dilated but there is volume loss in the parahippocampal white matter. No asymmetrical cortical atrophy. No cortical or basal ganglia diffusion restriction.

No significant intracranial stenosis on the MRA images.

Impression: Mild atrophy of the left hippocampal formation with associated volume loss in the medial temporal lobe. This could reflect early Alzheimer's dementia but as this is only mild progress imaging in a year is recommended. Alternatively a SPECT might assist.

MRI

MRI Brain (5 months later)

The lateral and third ventricles have increased significantly in size and cortical sulci diffusely are slightly wider, but there is no focal area of lobar atrophy. In particular, the mesial temporal structures are not atrophied out of proportion to the remainder of the brain, however there is an enlargement of the temporal horn of the lateral ventricles. 

The other major change is the development of new deep white matter focal ischaemic lesions, notably in the anterior limb of the right internal capsule and subependymomas in relation to both frontal horns. No restricted diffusion detected to suggest any recent lesion. The perfusion study shows patchy decreased perfusion, with most marked loss in left parietal lobe (not shown).

Conclusion: Evidence of further deep white matter ischaemic change and patchy cerebral perfusion. No anatomical features diagnostic of Alzheimer's disease, nor of focal lobar atrophy.

Annotated image

Diagram demonstrating ventricular enlargement in 5 months of AD progression. MTA stands for medial temporal lobe atrophy score. 

Case Discussion

This patient was clinically diagnosed with Alzheimer's disease (AD). Both MRI scans were performed within an interval of 5 months, the patient has been showing progressive cognitive impairment. 

Despite the difficulties to demonstrate AD on imaging, this case illustrates a progressive global cerebral atrophy observed in a short interval of time. When applying the medial lobe atrophy score for assessing the images, is possible to say that the patient moves from MTA 1 to MTA 2 in this period.

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Case information

rID: 37720
Case created: 19th Jun 2015
Last edited: 1st Jan 2016
Tag: rmh
Inclusion in quiz mode: Included

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