Dr. Pepe’s Diploma Casebook: Case 19 – SOLVED!


Dear Friends,

The following case depicts MRI images of a 59-year-old woman with rapid cognitive decline, progressive change of character, ataxia and diplopia.

1. Posterior reversible encephalopathy
2. Wilson disease
3. Creutzfeldt-Jacob disease
4. None of the above


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    7 Responses to : Dr. Pepe’s Diploma Casebook: Case 19 – SOLVED!

    1. Kelvin says:

      Restricted diffusion in the thalamus, caudate, and lentiform nuclei (high signal on the heavily B weighted image, corresponding low signal intensity on ADC).

      Pattern is mostly suggestive of CJD, probably the variant form.

    2. Alice says:

      I also choose No.3; CJD.

    3. Albert says:

      PRES (although could has thousands of faces) should be distributed around posterior circulation territories. The most often manifestation is a vasogenic edema, wich by definition has incresead difussion, in the occipital lobes. The clinical seeting is also helpful to establish the diagnosis (its usually associated with arterial hypertension and courses with headache and visual alterations as the most often manifestations.
      Wilson usually affects the basal ganglia in this distribution (although most often not the whole thalam)and could has a restricted diffusion in early phases. The clinical setting is usually also helpful. The most characteristic feature is the T1 hyperintensity.
      CJD is the one of the three possibilities that is more possible in the clinical setting and more over the restricted diffusion is the most important feature to suggest the diagnostic as far as I concern.
      Other possibilities I would contemplate are the hypoxic-ischemic encephalopathy and the osmotic myelinolisis (both should have an specific clinical sceneraio); and on the other hand vascular etiology (ischemia), specially deep venous thrombosis and posterior circulation arterial infarcts (including Percheron artery variants) -the symptoms should be more abrupt-.
      Summarising, I would choose (obsvisously in the clinical scenario and obviating all the other sequences) CJD. Anyway, I think it is not possible to establish the diagnostic only with these images.

    4. Ricardo Macareno says:

      Creutzfeldt-Jacob disease

    5. Isobel says:

      MRI findings and clinical presentation are strongly sugestive of CJ

    6. pax says:

      wilson dz