Jean Yves Gauvrit, Dementia daily exploration, jfim ifupi milan 2018
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Jean Yves Gauvrit, Dementia daily exploration, MRI assessment jfim ifupi milan 2018
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Jean Yves Gauvrit, Dementia daily exploration, jfim ifupi milan 2018
- 1. Dementia: daily exploration Prof. Jean-Yves Gauvrit – Prof. Jean-Christophe Ferré Radiology and Medical Imaging Dept., Rennes University Hospital, France 1st Italian-French Update Imaging – IFUPI Advanced Multiparametric Imaging - How to use in daily practice MILAN March 23-24 2018
- 3. MRI of dementia 3 Why? When? How? Diagnostic approach? Why? • Role of imaging (metabolic and morphological ) • Rule out differential diagnoses • Search for causes of secondary dementia (vascular damage) • Search for evidence of primary degenerative dementia (atrophy)
- 4. MRI of dementia 4 Why? When? How? Diagnostic approach? When? • HAS* 2011 recommendations • A brain scan recommended in all cases of recently (< 6 months) discovered dementia. * French National Authority For Health
- 5. MRI of dementia 5 Why? When? How? Diagnostic approach? When? How? • HAS 2011 recommendations • A brain scan is recommended in all cases of recently discovered dementia • MRI, otherwise a brain CT scan • No contrast agent In practice: Issue of MRI waiting periods
- 7. MRI of dementia • Search for and locate atrophy • Volumetric/anatomic sequence • Correction of head positioning errors • Reconstruction in 3 spatial planes: • Coronal perpendicular to hippocampal long axis • Sagittal (anterior-posterior gradient) • Axial 7 Why? When? How? Diagnostic approach? How? F 3D T1 Axial FLAIR Coronal T2 Axial T2* Axial Diffusion
- 11. 11 Why? When? How? Diagnostic approach? F 3D T1 Axial FLAIR Coronal T2 Axial T2* Axial Diffusion • T2* = gradient echo T2 Search for bleeding sequelae • Search for microbleeds • Marker for microangiopathy • Association between microbleeds and cognitive decline • Link between lobar microbleeds and cerebral amyloid angiopathy MRI of dementia How?
- 12. 12 Why? When? How? Diagnostic approach? F 3D T1 Axial FLAIR Coronal T2 Axial T2* Axial Diffusion • SWI: susceptibility weighted imaging • "Super" T2* • Improves • spatial resolution • sensitivity to magnetic susceptibility effects • detection of microbleeds Haacke et al AJNR 1997 70-year-old woman, cognitive disorders MRI of dementia How?
- 15. MRI of dementia 14 Why? When? How? Diagnostic approach? Why? • Differential diagnosis • Normal aging • Search for causes of secondary dementia (vascular damage) • "Curable" neurosurgical causes • Subdural hematoma • Tumor • Hydrocephalus • Vascular causes • Microangiopathy • Hereditary vascular dementia • Other secondary causes • Limbic encephalitis • Creutzfeldt-Jakob disease • Search for evidence of primary degenerative dementia 3D T1 Axial FLAIR Coronal T2 Axial T2* Axial Diffusion Diagnostic approach
- 16. MRI of dementia 15 Why? When? How? Diagnostic approach? Diagnostic approach "Normal" aging Brain volume abnormalities • From the age of 50: - 0.3% per year • Enlargement of sulci and cisterns • Progressive enlargement of ventricles • Diffuse atrophy of the entire brain • But inconstant atrophy • (« it's not because we're old, we have demantia») Diffuse cerebral atrophy Normal brain volume
- 18. MRI of dementia 17 Why? When? How? Diagnostic approach? Diagnostic approach "Normal" aging White matter abnormalities • 95% prevalence after the age of 60 • T2 hyperintensity, punctiform, then confluent • Periventricular spaces • Centrum semiovale, collateral trigones • More pronounced if cardiovascular risk factors • Other locations described • Splenium of the corpus callosum, optic radiations FLAIR
- 19. MRI of dementia 18 Why? When? How? Diagnostic approach? Diagnostic approach "Normal" aging White matter abnormalities Prins, N. D. & Scheltens, P. Nat. Rev. Neurol. 2015 • Fazekas 0: No hyperintensity • Fazekas 1: Focal or punctiform lesions • Single lesion ≤ 9mm • Cluster of lesions < 20mm • Fazekas 2: Early confluent lesions • Single lesions 10–20mm • Cluster of lesions > 20mm in all diameters • "Bridging" between the lesions • Fazekas 3: Confluent lesions • Isolated lesions > 20mm or areas of confluent hyperintensity ≥ 20mm in all diameters Fazekas et al. AJR Am. J. Roentgenol. 1987
- 20. MRI of dementia 19 Why? When? How? Diagnostic approach? Diagnostic approach "Normal" aging • Increase with age/hypertension • Clinical impact depends on volume and location • More common in the presence of dementia (vascular or not) • Recognized cause of cognitive decline (particularly integration functions) • Risk of developing dementia depends on initial severity and progression • Small punctiform lesions (Fazekas 1): very common but of little clinical interest • Fazekas 2 and 3 in a patient with cognitive decline: management and treatment of cardiovascular risk factors FLAIR White matter abnormalities and dementia Prins, N. D. & Scheltens, P. Nat. Rev. Neurol. 2015 Vascular dementia
- 21. MRI of dementia 20 Why? When? How? Diagnostic approach? Diagnostic approach "Normal" aging Gray matter abnormalities • Basal ganglia calcification • Bilateral/symmetrical • Variable signal on MRI • Basal ganglia iron deposition • Visible on MRI: hypointense signal on T2 • Increases with age from 25 onwards in the • Globus pallidus • Red nuclei, substantia nigra • Dentate nuclei • And then in the putamen from the age of 80
- 22. MRI of dementia 21 Why? When? How? Diagnostic approach? Diagnostic approach Primary degenerative dementia • Demonstrate focal atrophy of primary degenerative cortical dementia • Cortical atrophy initially localized before becoming more generalized • Correlations between clinical symptoms and focal cortical damage
- 23. MRI of dementia 22 Why? When? How? Diagnostic approach? Diagnostic approach Primary degenerative dementia Alzheimer's disease • Internal temporal atrophy • Predominantly in medial temporal and parietal lobes • Early atrophy of entorhinal cortex (Brodmann area 28) and hippocampus • Enlarged temporal horns
- 26. MRI of dementia 25 Why? When? How? Diagnostic approach? Diagnostic approach Primary degenerative dementia Assessment of internal temporal atrophy April 2012 December 2016 Colliot et al. Radiology 2008 Importance of the rate of atrophy progression Progression of hippocampal atrophy: • Alzheimer's between 2 and 6%/year • Controls between 0.5 and 1.5%/year
- 30. MRI of dementia 29 Why? When? How? Diagnostic approach? Outlook Arterial spin labeling • MRI technique that studies brain perfusion • Non-invasive • Non-radiating • No exogenous contrast agent • Quantitative • Cerebral blood flow • Reliable and reproducible • Main drawback: Poor signal-to-noise ratio • MRI sequences available but use is confidential Detre et al. MRM 1992, Ye et al. MRM 2000, Petersen et al. Neuroimage 2010
- 31. MRI of dementia 30 Why? When? How? Diagnostic approach? Outlook PET-MRI • PET-MRI: the multimodal imaging of tomorrow • PET and MRI show complementarity and synergy • MRI is the reference modality: • Gross anatomy • Molecular analysis • Vascular exploration • PET: radiotracers markers of receptors, specific metabolic processes