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MRI report showed moderately severe patchy and confluent leukoencephalopathy. Having slurred speech. Treatment?

my mother was seen in the ER last year for r/o TIA. I was on the phone with her and she had rapid and sudden onset of slurred speech and was also repeating the same comment over and over. A CT of the head w/o contrast was dome and showed the following: -ventricles/sulci unremarkable -moderately severe patchy and confluent leukoencephalopathy present, consistent with changes secondary to microvascular disease. -scattered chronic lacunar infarcts are seen in basal ganglia and external capsules bilat. -superimposed acute infarct can not be excluded. Her hx is of mild HTN, on exforge . Mildly elevated chol, but with good ratio and excellent HDL and low triglycerides. Hx of cigarette smoking. 1/2-1pack/day x 20+ yrs and was smoking at the time of this ER visit. Fam Hx of Hashmotos thyroiditis in ALL females for at least 3 generations. Hx of anxiety, Reynauds, B12 deficiency and B12 deficient anemia. Also c/o palpitations and had a greatly increased pulse rate (100-140) intermittently. She was prescribed Xanax .25mg prn, and after 2 days admitted and on a holter monitor was sent home being told to quit smoking and gain weight . She had not been eating, c/o either her new dentures hurting too much or stomach spasms causing intense pain (previously seen and treated by rx of Bentyl prn) Hospital intake stated she was cachectic . A follow up MRI of the brain was done as well with the following findings: -cystic changes noted to choroid plexus in trigone region of lateral ventricles -very small foci of cystic encephalomalacia within the basal ganglia and thalami are identified -moderately extensive, patchy and confluent foci of abnormal T2 signal are spread around the periventricular white matter of both cerebral hemispheres, and also noted within the midbrain and pons -scattered paranasal mucoperiostal thickening with no significant sinus opacification Can you PLEASE sum this up? I am a nurse, and while I understand most of this, the doctors where she was treated told her she didn t have a stroke or TIA...or at least that is what my mother came away thinking. However, am I incorrect that what I am seeing is that she has evidence of multiple small, deep, old strokes present, as well as diffuse white matter disease/small vessel disease? I ask because I have seen a marked change in my mom since this began. She becomes angered more easily, jumping on people. She seems to forget things I have told hre just a few days/weeks ago, she exhibits almost manic/depressive type swings, she does not plan well, and she laughs and/or reacts inappropriately. She also has episodes of extreme anxiety and cries uncontrollably saying she can t stop . These all seem to me to be symptoms of Vascular Dementia, no? My Dad was diagnosed with colon cancer this past summer, and I am an only child trying to care for them both...please help me understand these results. I feel she needs further evaluation...
Asked On : Sat, 19 Jan 2013
Answers:  2 Views:  795
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Psychiatrist 's  Response
Hi,
Thanks for writing in to us.

Sorry to hear that you are having a tough time having to care for both parents who been ill for a while. Coming to your mom's ER visits, from the CT scan findings, there is mention of periventricvular white matter changes due to microvascular disease and scattered chronic lacunar infarcts are seen in basal ganglia and external capsules bilaterally. These refer to mini strokes in the past which might have gone unnoticed.

Further, as the CT scan could not be conclusive regarding an underlying acute infarct, a follow up MRI scan was done. As per MRI report there are cystic changes noted to choroid plexus in trigone region of lateral ventricles -very small foci of cystic encephalomalacia within the basal ganglia and thalami are identified -moderately extensive, patchy and confluent foci of abnormal T2 signal are spread around the periventricular white matter of both cerebral hemispheres, and also noted within the midbrain and pons. This also does not pin point to any acute cerebrovascular event.

Your suspicion on possibility of Vascular Dementia needs imaging and clinical coreelation. One of the most useful tests in the evaluation of Vascular Dementia is magnetic resonance imaging (MRI). The MRI is very sensitive to changes in the brain caused by stroke. The principal findings in Vascular Dementia are lacunar infarcts (small, spherical strokes in the deep parts of the brain) and abnormal findings in the cerebral white matter. This is the region where axons (the long part of a nerve cell) travel. It is called the "white matter" because the fatty insulation on the axons makes it look white in real life. These changes can be seen in many people who appear to have no cognitive complaints, however, studies have shown that as the total volume of these changes increases, cognitive difficulties are more likely.

Clinically Vascular Dementia needs to be differentiated from Alzheimer's Disease. A Psychiatry consultation and work up will help you further.

Hope this helps
Answered: Wed, 7 Aug 2013
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