A 70-year-old woman is evaluated for an episode of - epi

[ArchivalUser]

A 70-year-old woman is evaluated for an episode of abrupt cognitive decline that began 2 weeks ago when she was suddenly unable to read the newspaper during breakfast. She could not find the bathroom in her own home but could carry on a conversation and recognize family members. Her condition has since improved. She has a history of hypertension and coronary artery disease, and has been forgetful over the past few years.

On examination, vital signs and general physical examination are normal. Her score on Mini“Mental State Examination is 22/30. She is not oriented to time or place. Neurologic examination is normal except for a left Babinski sign. CT scan of the head shows bilateral periventricular white matter hypodensity. Three months later, she is oriented to place and has improved daily function, a score on Mini“Mental State Examination of 24/30, and a normal neurologic examination, except for the Babinski sign.

Which of the following tests would be most useful for the diagnosis of this patient's cognitive impairment?

A Carotid ultrasound (duplex) evaluation
B Analysis of cerebrospinal fluid for 14-3-3 antigen
C Electroencephalography
D Repeat brain imaging
E Analysis of blood for presenilin 1 mutation

[ArchivalUser]

i wud CONSIDER MS..bt this pts age is worrying me..isnt ms too old for ms...n seeing the rapidly progressive course..bt memory impairment has been for few yrs...
so stepwise downward thing with improvement n then again going down..
multiinfarct dementia..
answer wud be ..
A

[ArchivalUser]

try again harsh

[ArchivalUser]

cjd..bbb..bt its rapidly progrssive course n myoclonus..

[ArchivalUser]

seeing the symtoms wax and wane...I think the answer is A...but you are saying 'try again'...is the answer D?

[ArchivalUser]

Yes D is the correct answer

Key Point
Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.

This patient probably has vascular dementia, because of the history of vascular risk factors, abrupt onset with subsequent improvement, suggestion of periventricular white matter ischemia on imaging, and a focal neurologic sign (Babinski sign). Follow-up imaging may demonstrate a recent infarct not yet evident on the earlier scan that can be temporally associated with the episode of cognitive decline.

Many patients with coronary artery disease have carotid artery stenosis, but carotid artery evaluation will not support a diagnosis of vascular dementia.

Analysis of cerebrospinal fluid for 14-3-3 antigen is appropriate only for evaluation of subacute dementia with normal brain imaging studies, that is, to support a diagnosis of Creutzfeldt“Jakob disease. In this case, in which cerebrovascular disease is the most likely explanation, the neuronal damage due to a recent cerebral infarct might give a falsely elevated 14-3-3 test. Also, this patient has had a partial remission, which is not characteristic of Creutzfeldt“Jakob disease.

Electroencephalography can be useful to support a diagnosis of metabolic encephalopathy. However, in this patient, the focal neurologic sign (Babinski sign) indicates a structural disorder. Complex partial seizures might be invoked to explain encephalopathy followed by focal neurologic signs, but postictal signs usually do not persist longer than a few hours. Ultimately, imaging is the more direct way to evaluate a focal structural disorder.

Presenilin 1 gene testing is used only for the evaluation of familial primary dementia, or presenile dementia.