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Brain scan shows white matter hyperintensities, bilateral old lentiform nuclei lacunar infarcts. See a neuropsychiatrist?

I am a 64-yo female with longstanding PMH of hypertension (28 years), well controlled on meds for the most part. I was diagnosed with diabetes in 11/2010, having been intermittently symptomatic for at least 3 years prior. Since DX, A1c levels have trended down from 7.0 to current level of 5.8, taking metformin and with dietary changes. Chronic depression/anxiety/stress of 20+ years is also adequately controlled with meds, but has been subject to ongoing unemployment woes since 11/2009 and consequential financial problems. Over the past 2 years I have noticed initially subtle, now gradually progressive mental status changes such as loss of focus and concentration, cognitive deficits affecting thinking, reasoning, decision-making and memory , plus mild expressive and receptive dysphasia signs. I asked my FP/PCP to order a brain scan w/wo contrast. The results I received last week are as follows: 1. Scattered nonspecific punctate bilateral frontal, bilateral parietal and left subinsular white matter T2/FLAIR hyperintensities may represent chronic microvascular ischemic changes, described in the impression as supratentorial and age-appropriate. 2. Bilateral old lentiform nuclei lacunar infarcts, the extent of which was not described. Having been a medical transcriptionist for 30+ years, I ve read a bit about both findings, and am vaguely familiar with the functions of these cerebral regions and the described processes, but I have two questions. I am assuming that either or both conditions are contributing to the mental status changes....particularly the bilateral lacunar infarcts. I originally thought these symptoms were attributable to chronic depression/anxiety/stress and the unemployment/financial problems. In your opinion, am I over-reacting to this news by making that assumption? Also, in view of these newly diagnosed deficits, would it be beneficial for me to consult with a neuropsychiatrist? I am asking because I am planning to seek counseling/ therapy for these problems since I need to re-enter the workforce. I am wondering if and how these conditions change the therapeutic approach. Specifically, I believe tests to evaluate the degree of cognitive deficits is in order, as it would stand to reason they would impact the modalities used in a therapeutic treatment plan. Any insight you can offer would be greatly appreciated.
Asked On : Thu, 14 Feb 2013
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Neurologist 's  Response
I have noted all your complaints, imaging data.

The imaging findings that you have can be seen in patients with high blood pressure and diabetes. The infarcts that you have described is also seen in patients with these problems. The most important thing to note is that whether you had any stroke in the past or not. People with high BP and diabetes can have this MRI changes without much problem also. So it is unwise to interpret this data without any clinical correlation. Regarding the cognitive problems as well as anxiety etc, this may represent a type of executive dysfunction which may/may not have relation with the current MRI findings. Interestingly some people can have both depression/anxiety as well as cognitive problem due to organic disease.

Please undergo a joint evaluation by a neuro-psychiatrist, clinical neurologist as well as by a psychiatrist. Their clinical evaluation will tell us if you have any organic cognitive problem or not so that we can plan our treatment accordingly.

Hope this helps
Answered: Sat, 16 Feb 2013
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