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DOI 10.1007/s00330-015-3957-z
NEURO
Abstract
Objectives Dementia is foremost a clinical diagnosis.
However, in diagnosing dementia, it is advocated to perform
at least one neuroimaging study. This has two purposes: to
rule out potential reversible dementia (PRD), and to help determine the dementia subtype. Our first goal was to establish if
MRI combined with visual rating scales changes the clinical
diagnosis. The second goal was to demonstrate if MRI contributes to a geriatricians confidence in the diagnosis.
Methods The dementia subtype was determined prior to and
after MRI. Scoring scales used were: global cortical atrophy
(GCA), medial temporal atrophy (MTA), and white matter
hyperintensity measured according to the Fazekas scale. The
confidence level of the geriatrician was determined using a
visual analogue scale.
Results One hundred and thirty-five patients were included. After MRI, the diagnosis changed in 23.7 % (CI
17.0 %-31.1 %) of patients. Change was due to vascular
aetiology in 13.3 % of patients. PRD was found in 2.2 % of
all patients. The confidence level in the diagnosis increased
significantly after MRI (p = 0.001).
Conclusions MRI, combined with visual rating scales, has a
significant impact on dementia subtype diagnosis and on a
geriatricians confidence in the final diagnosis.
Key points
MRI with visual rating scales changes the dementia subtype
diagnosis significantly.
MRI is essential in demonstrating vascular disease as a
cause of dementia.
All suspected dementia patients should undergo an MRI with
visual rating scales.
MRI improves a geriatricians confidence in the diagnosis of
the dementia subtype.
MRI remains essential during the workup of dementia to
exclude reversible causes.
Keywords Dementia . Magnetic resonance imaging . Mild
cognitive impairment . Alzheimers disease . Dementia .
Vascular
Abbreviations
AD
Alzheimers disease
GCA
global cortical atrophy
MCI
mild cognitive impairment
MMSE mini mental state exam
MTA
medial temporal atrophy
PRD
potential reversible dementia
VAS
visual analogue scale
Introduction
* Martijn V. Verhagen
mverhagen@kg.nl
1
Eur Radiol
Methods
The study design consisted of a prospective observational single
centre study, performed in a general hospital (Spaarne Gasthuis,
Haarlem, the Netherlands) from October 2013 to July 2014.
Approval was acquired from the local institutional review board.
All patients with cognitive deterioration referred to our department of geriatrics were consecutively enrolled into the
study. The inclusion criterion was first presentation with cognitive deterioration; exclusion criteria were inability to undergo
MRI (e.g., because of a pacemaker or inability to remain still),
neuroimaging from elsewhere performed as part of the workup
of cognitive deterioration, known neurodegenerative disease or
significant brain damage, and/or a known brain tumour.
Patients were evaluated by one of four geriatricians, all with
more than five years of clinical experience with dementia. Depending on the specific needs of the patient, the
geriatrician consulted supporting specialists (e.g., a neurologist, neuropsychologist and/or psychiatrist). A mini
mental state examination (MMSE) [19] and clock drawing test were determined in all patients. Vascular comorbidity, prior cerebral vascular accident (CVA), diabetes,
history of smoking, heightened cholesterol levels, and
blood pressure were retrieved from the patient file.
All patients underwent an MRI examination as part of the
standard workup of cognitive deterioration in our hospital.
The MRI studies were examined as part of a daily workload
by one of five radiologists, all with more than five years of
experience with neuroimaging. Studies were examined and
reported according to standard practice. The visual rating
scales used were; global cortical atrophy (GCA) [16], medial
temporal atrophy (MTA) [14, 15], and white matter
hyperintensity according to the Fazekas scale as a measure
for small vessel ischaemic disease [17]. Regional or asymmetric atrophy not included in the visual rating scales was reported separately, as is part of the normal routine.
During a weekly multidisciplinary meeting the geriatrician
was asked to determine the diagnosis, differential diagnosis,
treatment plan, and level of confidence in the diagnosis by
means of a visual analogue scale (VAS) both prior to, and after
assessing the neuroimaging study accompanied by the radiology report. The MRI study and radiology report were blinded
to the geriatrician until the multidisciplinary meeting.
Only in the case of PRD were the findings immediately
communicated with the geriatrician without waiting for
the weekly meeting. PRD included any potentially reversible or surgically treatable pathology such as brain tumours or
subdural haemorrhage (SDH). The geriatricians final diagnosis was used as the diagnostic standard. The VAS ranged from
Eur Radiol
Results
In the period from October 2013 to July 2014, 148 patients
were enrolled into the study. 131/148 (88.5 %) patients were
referred to a geriatrician by their general practitioner, the remainder were referred by a neurologist. 13 patients were excluded because they could not undergo MRI, these patients
subsequently underwent CT. The population that underwent
MRI had an average age of 75.5 years (median 77, standard
deviation (SD) 9.4, range 45-93), and an average MMSE of
25.6 (median 26, SD 3.2, range 16-30). PRD was reported in
3/135 (2.2 %) patients undergoing MRI: 2 primary brain
Eur Radiol
Table 1
Demographics
AD
Age (SD)
Gender (% male)
MMSE (SD)
41 (30.4)
40 (29.6)
77.9 (7.9)
35
23.2 (3.6)
AD + vascular component
5 (3.7)
9 (6.7)
82.9 (5.9)
33
23.9 (2.6)
MCI
MCI + vascular component
62 (45.9)
5 (3.7)
51 (37.8)
9 (6.7)
76.3 (6.8)
79.7 (5.9)
49
67
26.7 (2.0)
26.9 (2.1)
2 (1.5)
2 (1.5)
1 (0.7)
2 (1.5)
79
84
100
100
23
26
Frontotemporal dementia
1 (0.7)
1 (0.7)
84
100
Depression
PRD
6 (4.4)
3 (2.2)
9 (6.7)
3 (2.2)
62.3 (9.9)
75 (2.8)
44
50
27.8 (1.9)
25.0 (5.7)
8 (5.9)
135
10 (7.4)
135
60.1 (10.5)
75.5 (9.4)
67
47
27.9 (2.3)
25.6 (3.2)
Rest group *
Total
- Missing
2004, Condefer [21] already reported a 12 % change in diagnosis after a CT of the brain, however, the study was performed retrospectively, included only CT, and did not use
visual rating scales. We found a 23.7 % change (CI 17.0 % 31.1 %) in diagnosis after MRI in a prospective study including visual rating scales; we confirm and provide stronger evidence for the significant impact of neuroimaging on the final
dementia subtype diagnosis.
Change in diagnosis was due to the detection of a vascular
aetiology in a significant group of patients (13.3 % of all
patients). This confirms that it is difficult to assess vascular
comorbidity based on clinical findings alone. The demonstration of vascular abnormalities has therapeutic implications; for
described. Patients diagnosed with MCI or AD were significantly older than patients in the depression group and the rest
group without cognitive impairment (p = 0.001). MMSE was
significantly lower in AD compared to all other groups (p =
0.001). The clock drawing test was significantly more often
false in the AD group compared to all other groups (p = 0.02).
Discussion
The purpose of this study was to establish the impact of MRI
of the brain, combined with visual rating scales, on the clinical
workup of patients presenting with cognitive deterioration. In
Same diagnosis
Different diagnosis
65.0 %
44.4 %
78.4 %
33.3 %
55.6 %
70.0 %
63.0 %
17.5 %
55.6 %
5.9 %
66.7 %
33.3 %
20.0 %
23.7 %
17.5 %
0%
15.7 %
0%
11.1 %
10.0 %
13.3 %
Eur Radiol
Table 3
Change in diagnosis
AD
AD + vascular component
MCI
AD+vasc
MCI
Total
MCI+vasc
LBD
VD
FTD
Depression
Rest*
8
1
1
5
14
2
1
VD
FTD
Total
2
1
1
5
29
Mean Change
VAS (SD)
AD
AD + vascular component
MCI
MCI + vascular component
Lewy body dementia ^
78.1 (15.5)
80.3 (10.4)
82.3 (17.1)
84.7 (8.5)
90
86.8 (11.8)
86.3 (14.7)
90.6 (10.8)
89.8 (10.4)
70
+8.7 (9.8)*
+6.0 (6.7)
+8.3 (14.4)*
+5.2 (8.1)
-20
Vascular ^
Frontotemporal ^
Depression
Rest group *
Total
67
85
85.8 (13.4)
80.7 (17.8)
80.9 (15.04)
94
70
88.5 (11.3)
84.9 (13.8)
87.8 (11.85)
+27
-15
+2.8 (3.4)
+4.1 (9.9)
+6.9 (11.5)*
^ n = 1 or 2
* p < 0.05
* no objective cognitive impairment
AD: Alzheimers disease
MCI: Mild cognitive impairment
VAS: Visual Analogue Scale (0-100)
Eur Radiol
Table 5 Vascular pathology
findings
Vascular pathology
AD
AD+vasc
MCI
Number of patients
51
40
MCI+vasc
9
2.22 (1.09)*
3.00 (0^)
1.29 (0.91)
2.44 (0.53)*
1.29 (0.91)
Microbleeds
Lacunes
2
3
9 (22.5 %)
5 (55.6 %)
5 (9.8 %)
2 (22.2 %)
VD
0 (0 %)
^n=2
* p < 0.05
AD: Alzheimers disease
MCI: Mild cognitive impairment
Vasc: Vascular component
VD: Vascular dementia
Eur Radiol
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