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What are the symptoms of cerebral atrophy?

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Posted on Wed, 13 May 2015
Question: Can you explain the finding below for me, a 65 year old woman with a family history of Alzheimer's. I have been having memory issues which seemed to be worsening so I had a SPECT scan done (Dr. XXXXXXX Amen's clinic). I have also been diagnosed with major depressive order with anxiety. The Clinic doctor didn't even comment on the finding below, but after reading online about it, it's very concerning to me. I had a brain fMRI about 5 years for another issue and nothing was mentioned about cortical atrophy. I would appreciate another opinion as I'm pretty much into panic mode.

Thanks,
Linda


3: Evidence of cortical atrophy is noted. The most significant findings are the severely decreased activity in the Sylvian and longitudinal fissures that suggest early cortical atrophy and/or a brain injury.

Cortical atrophy may be seen in aging, as a result of trauma, anoxic events, vascular disease, strokes and chronic toxicity (alcohol, drugs, inhalants, toxic exposure, chronic hypoxia, metabolic diseases). Developmental disorders affecting neuronal migration in utero may also result in this appearance. Cortical atrophy is suspected if there is a decrease in activity in the region of the Sylvian fissures (lateral aspects of temporal lobes where the lobes touch the frontal and parietal cortices) as well as in the region of the longitudinal fissure (the line where the two cerebral hemispheres meet) - commonly at the frontal poles. In addition, there may be scalloping and evidence of proportionate ventricular enlargement. Disproportion between atrophy and ventricular enlargement may present in a number of conditions, some of which may be amenable to intervention, thus, ventricular enlargement greater than the degree of atrophy requires close clinical correlation and possible follow-up imaging with MRI.


doctor
Answered by Dr. Olsi Taka (1 hour later)
Brief Answer:
Read below.

Detailed Answer:
I read your question carefully and I understand your concern. I am not sure whether the last paragraph came from you or was it an excerpt from a source you found on cerebral atrophy.

It would also be useful to know what other tests did you have, SPECT scanning is not a starting test, usually an MRI is the first choice test. It's not only a question of pricing and limited availability, I don't think it is the most suitable initial test either. So if you had an MRI before please tell us something on its results.
Also that report sounds a little too concise, please tell if there is more information on that report (perhaps could scan/photograph it and upload here)

Now regarding cerebral atrophy. Atrophy basically means shrinking due to loss of brain mass. You should know that some brain mass is lost for each and every one of us, starting from around the age at 25. It is a slow process and isn't detectable on imaging at a younger age, but as it accumulates it starts to become visible with the amounting of the years. So the fact it wasn't visible over your old imaging exams isn't a XXXXXXX

So as you see simply saying to have atrophy is not specific as it can be found with normal aging. On the other hand it can be as an aftermath of pathological conditions such as past stroke, trauma, infection etc. However in most of these cases the atrophy would be asymmetrical, localized in the area damaged by stroke or trauma.
In your case the findings are described as symmetrical which don't correspond to the above-mentioned conditions. So that leaves to be considered the possibility of dementia which is also what your memory issues might suggest and which commonly manifests early cortical atrophy as per the report.
So what is suggested by that report is the possibility of cognitive impairment which could evolve in dementia in the future, there are many types of dementia with Alzheimer's being the most common one.
However atrophy on imaging isn't a sentence, it doesn't make the diagnosis even if the atrophy is considered early for your age. The brain volume doesn't always strictly correspond with cognitive impairment and it is considered significant only when there are cognitive impairment issues, so you need neuropsychological tests to assess memory as well as other cognitive functions. Only the scores of those tests indicate dementia, not imaging.
If the tests confirm cognitive impairment some more tests will be needed for alternative causes of dementia such as vitamin B12 deficiency or thyroid disorders (perhaps you might already have had these tests, please tell if that is the case).
As for differentiating whether it is a case of Alzheimer or another type of dementia imaging could help, but in your report very scant data are included, that is why I asked on more detailed reports earlier. What I look for in an imaging report to evaluate for dementia is which lobes and structures (like hyppocampus) have more pronounced atrophy on MRI. Meanwhile on functional MRI like SPECT or PetScan I would look for perfusion and metabolism changes in those areas. For Alzheimer's on PetScan could be searched for amyloid depositions.

So all these useful data are lacking on that report, it speaks simply of brain shrinking to detect which a simple CT scan would have been enough.

So bottom line for now, all that can be said is that neuropsychological tests are needed to differentiate atrophy related to aging from early dementia. If tests indicate dementia more tests are needed to determine the source.

I remain at your disposal for further questions, possibly with more info on other tests you may have had (as I doubt you were rushed straight into SPECT scanning).

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (1 hour later)
Thanks for your thorough reply. What I gave you came from the report itself, I didn't copy anything off the web. There is greater detail in the report about other areas of the brain, but don't have an electronic version. There were many tests that measured cognitive activity, not just the scans. I performed exceptionally well on executive functioning skills but performed lower than an average 65 year old on working memory. I'm not at home so can't even give you the names of the tests, but they included remembering sequence of numbers, words, counting backwards in 7's from 100, drawing a certain time on a clock, being given three words to repeat in the beginning of my conversation with psychologist and them asked at the end of the interview to recall them, response time on an online test of only hitting the space bar when the letter "x" did not show up. So there were many other tests where I performed averahe to above average on (except for working memory). Just also majorly depressed (for months) with very high anxiety levels. So would your recommendation be to see a neurologist?
doctor
Answered by Dr. Olsi Taka (52 minutes later)
Brief Answer:
Read below.

Detailed Answer:
Ah, I see so I guess it was general information included in the report. I imagine that you don't have an electronic version of the report, I was thinking you could perhaps just snap a shot with your smartphone or scan it and upload if it's technically possible for you. That's what other users often do and me myself when I want to have a copy of a paper I want to review later I just photograph it with my smartphone. If you can't it's not a big deal do not want you to go to much trouble over it.

The fact that most of your tests resulted with good scores is great news, dementia by definition is diagnosed when it affects other cognitive functions (language, judgment, executive functions etc) not just memory. Actually working memory tests can be influenced by factors such as depression and anxiety which affect attention, so since you report them as well it could be the explanation for the below average performance. So in the light of those tests it could well be for brain atrophy to be in the setting of aging.

I believe a neurological consult should be scheduled anyway for a physical neurological evaluation for other neurological signs other then cognition (like parkinson's signs, neurological deficits related to vit B12 deficiency, signs of thyroid dysfunction etc) and a final correlation of the imaging and neuropsychological and lab test results. A neurologist is the most appropriate specialist for that.
At times a final conclusion can not be drawn at this moment in time, but it can be used as a starting point and a re-evaluation might be scheduled in say 6-12 months time to compare neuropsychological and imaging tests changes. If depression and anxiety are thought to play a role during this follow-up time treatment for them might be taken in order to see the difference on re-evaluation.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (21 hours later)
Hi,
I attached the report (pretty brief) and the images themselves. I have ones for a normal woman my age if you'd like that as well. Let me know if anything here clarifies anything for you. Thanks.

Linda
doctor
Answered by Dr. Olsi Taka (13 hours later)
Brief Answer:
Read below.

Detailed Answer:
Thank you for that detailed report. I read it carefully.

My opinion remains pretty much unchanged. You have some cerebral atrophy, more marked in the frontal and temporal lobes, which calls attention for the evaluation for dementia but if the neuropsychological tests are normal not too much must be read into it as it might be only a normal variation related to aging and for the moment only follow-up is necessary in that regard. Of course depression and anxiety must be treated accordingly.

On a side note if you remember I wondered in my first answer how come it was started with SPECT which is not the first tool which comes to mind, is available only at selected centers and its interpretation and applications are still being researched. Now after you asked if you should see a neurologist I searched for XXXXXXX Amen's name to see his specialty and I realized that while not that known this part of the world he is a sort of celebrity in the US.
While I am sure he's a clinically able psychiatrist from what I read it is not only me who was left puzzled by SPECT diagnosing, but there are many renowned names in psychiatry who accuse him about his overuse of SPECT to make a diagnosis. Perhaps you might be aware of this debate but I'm including a link just in case.
http://www.washingtonpost.com/lifestyle/magazine/daniel-amen-is-the-most-popular-psychiatrist-in-america-to-most-researchers-and-scientists-thats-a-very-bad-thing/2012/08/07/467ed52c-c540-11e1-8c16-5080b717c13e_story.html

I repeat that he's a distinguished psychiatrist, more than capable of treating conditions like depression, anxiety, dementia so you certainly can continue to be followed by him. I wanted only to warn you from putting too much emphasis on SPECT results because it's not only me but also far more renowned figures in neurosciences who still believe clinical diagnosis is much more important than imaging.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (6 hours later)
Thank you. I am aware of the controversy around Dr Amen; it's just that traditional medicine hasn't helped at all with my depression, anxiety. I just wanted a different perspective. I'm concerned that the consulting psychiatrist refused to definitively say I had atrophy when it was clearly on the report. It doesn't help me to misrepresent the information...or perhaps he didn't want to rely on the SPECT scan for diagnosis because of the controversy associated with it. He just kept on saying those areas of the brain weren't being "activated,"...well, you can't activate something that's not there.

I'm attaching the psychological testing scores and definition of terms. The tests consisted of two half hour online tests. This is what the Amen psychiatrist also used in his diagnosis. Would appreciate any comments. You've been so very helpful!! I do plan on seeing a neurologist, but unfortunately timing is bad as I'm starting a new job a week from Monday and taking time off for consult's, testing, etc., will probably be challenging for the next 6 months.

What do you think of frontaltemporal dementia? I seem to fit many of the diagnostic criteria. (as you can see I am unfortunately becoming very obsessed with this--which is not good, given I'm starting a new job so soon).

Linda

P.S. Promise this will be the last email I send except to say "thank you" again.
doctor
Answered by Dr. Olsi Taka (2 hours later)
Brief Answer:
Read below.

Detailed Answer:
Thank you for sending those reports and no worry you can ask as many questions as you need to.
The reports confirm what you already told me, that other than working memory other areas are not affected. I can understand the psychiatrist not wanting to define as atrophy because in my opinion the best exam to determine brain mass is simple MRI, not SPECT, it gives other complementary useful information, but for the atrophy itself MRI is better I think.

I was kind of expecting you to think about fronto-temporal dementia (FTD), clinically doesn't look likely though as memory impairment which is about the only thing detected in tests is not among the earliest signs of it, memory as initial manifestation is more typical for Alzheimer's. In FTD according to its subtype more prominent are behavior changes with involvement of inhibition, executive functions or language. So for now it doesn't look very likely, time will tell.

One thing I forgot to mention is that activation pattern changes can be related also to your depression and anxiety. Also bulimia which you mention to have suffered from has been found to be related to cerebral atrophy (not as strong a relation as anorexia, but it can be a contributing factor added to the aging).

So I have to repeat again that for now while you should receive treatment for depression and anxiety, there is not much proof towards dementia really. Future follow ups are recommended, but not as something to look forward to with apprehension. It certainly can wait for some months until you get settled in your new job, perhaps even better to be tested later rather than sooner, once depression and anxiety have improved as they can affect test results.

Best of luck with your new job.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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What are the symptoms of cerebral atrophy?

Brief Answer: Read below. Detailed Answer: I read your question carefully and I understand your concern. I am not sure whether the last paragraph came from you or was it an excerpt from a source you found on cerebral atrophy. It would also be useful to know what other tests did you have, SPECT scanning is not a starting test, usually an MRI is the first choice test. It's not only a question of pricing and limited availability, I don't think it is the most suitable initial test either. So if you had an MRI before please tell us something on its results. Also that report sounds a little too concise, please tell if there is more information on that report (perhaps could scan/photograph it and upload here) Now regarding cerebral atrophy. Atrophy basically means shrinking due to loss of brain mass. You should know that some brain mass is lost for each and every one of us, starting from around the age at 25. It is a slow process and isn't detectable on imaging at a younger age, but as it accumulates it starts to become visible with the amounting of the years. So the fact it wasn't visible over your old imaging exams isn't a XXXXXXX So as you see simply saying to have atrophy is not specific as it can be found with normal aging. On the other hand it can be as an aftermath of pathological conditions such as past stroke, trauma, infection etc. However in most of these cases the atrophy would be asymmetrical, localized in the area damaged by stroke or trauma. In your case the findings are described as symmetrical which don't correspond to the above-mentioned conditions. So that leaves to be considered the possibility of dementia which is also what your memory issues might suggest and which commonly manifests early cortical atrophy as per the report. So what is suggested by that report is the possibility of cognitive impairment which could evolve in dementia in the future, there are many types of dementia with Alzheimer's being the most common one. However atrophy on imaging isn't a sentence, it doesn't make the diagnosis even if the atrophy is considered early for your age. The brain volume doesn't always strictly correspond with cognitive impairment and it is considered significant only when there are cognitive impairment issues, so you need neuropsychological tests to assess memory as well as other cognitive functions. Only the scores of those tests indicate dementia, not imaging. If the tests confirm cognitive impairment some more tests will be needed for alternative causes of dementia such as vitamin B12 deficiency or thyroid disorders (perhaps you might already have had these tests, please tell if that is the case). As for differentiating whether it is a case of Alzheimer or another type of dementia imaging could help, but in your report very scant data are included, that is why I asked on more detailed reports earlier. What I look for in an imaging report to evaluate for dementia is which lobes and structures (like hyppocampus) have more pronounced atrophy on MRI. Meanwhile on functional MRI like SPECT or PetScan I would look for perfusion and metabolism changes in those areas. For Alzheimer's on PetScan could be searched for amyloid depositions. So all these useful data are lacking on that report, it speaks simply of brain shrinking to detect which a simple CT scan would have been enough. So bottom line for now, all that can be said is that neuropsychological tests are needed to differentiate atrophy related to aging from early dementia. If tests indicate dementia more tests are needed to determine the source. I remain at your disposal for further questions, possibly with more info on other tests you may have had (as I doubt you were rushed straight into SPECT scanning).