336 lines
22 KiB
Markdown
336 lines
22 KiB
Markdown
---
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title: "Multiinfarct Dementia"
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docid: "3823c4d4-5e98-46da-a717-892fef54b382"
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authors:
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- key: "9d40c5b1-57d2-442c-9daf-8d8d9d53e24b"
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value: "Akiva Mintz, MD, PhD, MHA, CFA"
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- key: "bbc899b6-2885-44bb-a5b0-24eec7314d33"
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value: "Bryan J. Neth, BS"
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- key: "1f262abe-db83-4f18-99af-00bd3045cd4d"
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value: "Marc Benayoun, MD, PhD"
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breadcrumbs:
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-
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name: "Nuclear Medicine"
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slug: "nuclear-medicine"
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treeNodeId: "2406533f-6523-4211-841e-b92d6f8cf34e"
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-
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name: "Central Nervous System"
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slug: "central-nervous-system"
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treeNodeId: "bd6b5c36-69df-4f18-af9c-96cc24b52d8f"
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-
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name: "Neurodegeneration"
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slug: "neurodegeneration"
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treeNodeId: "f2b87cc7-926d-4915-8ec5-ca61a82e8bc9"
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-
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name: "Multiinfarct Dementia"
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slug: "multiinfarct-dementia"
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treeNodeId: null
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category: "Nuclear Medicine"
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cmeTopicId: "29e9ca9b-f22e-44aa-94a4-19393851339d"
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documentVersionId: "2906e1eb-a93a-4cdb-8e7f-261c406e626c"
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imageCount: 24
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lastUpdated: "07/21/25"
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pageDescription: "Multiinfarct Dementia"
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pageKeywords: "Nuclear Medicine, Central Nervous System, Neurodegeneration, Multiinfarct Dementia"
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pageTitle: "Multiinfarct Dementia | STATdx"
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enhancedTitle: "Multiinfarct Dementia"
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type: "DX"
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references: true
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breadcrumbs:
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- "Nuclear Medicine"
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- "Central Nervous System"
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- "Neurodegeneration"
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- "Multiinfarct Dementia"
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---
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# KEY FACTS
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- ## Terminology
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- Impairments in cognition and behavior affecting functional status due to pathologic changes resulting from various vascular insults throughout brain
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- ## Imaging
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- F-18 FDG PET may be used in differential diagnosis between vascular dementia and Alzheimer disease
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- Glucose hypometabolism in multifocal (scattered) pattern of cortical with subcortical regions is indicative of vascular dementia
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- Multifocal or unifocal hypometabolism involving cortical gray matter, subcortical white matter, and other structures
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- Generally involves cerebral hemispheres, thalamus, basal ganglia, hippocampi
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- Amyloid PET imaging does not demonstrate gray matter amyloid deposition in vascular dementia
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- SPECT with Tc-99m HMPAO or Tc-99m ECD shows similar asymmetrically decreased perfusion
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- ## Pathology
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- Vascular-related lesions leading to loss of brain function
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- Chronic small vessel insults > large vessel infarcts
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- ## Clinical Issues
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- Significant heterogeneity in clinical presentation depending on location, type, and size of vascular lesion
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- Overt disease: Cognitive impairment due to clinically evident vascular event (i.e., stroke)
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- Covert disease: Insidious process of vascular insults (clinically silent strokes)
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- 2nd most common cause of dementia after Alzheimer disease
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# TERMINOLOGY
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- ## Definitions
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- Impairments in cognition and behavior affecting functional status due to pathologic changes resulting from various vascular insults throughout brain
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- Vascular cognitive impairment (VCI) is more comprehensive term incorporating vascular dementia (VaD) as well as other vascular-related cognitive impairment, including mild cognitive impairment due to vascular disease
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Multifocal or unifocal infarcts involving cortical gray matter, subcortical white matter, and other structures
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- Especially when correlates with other clinical findings
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- Generally involve cerebral hemispheres, thalamus, basal ganglia, hippocampi
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- Generally significant white matter involvement
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- Bilateral > unilateral
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- Size: Decreased due to atrophy
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- Morphology: Multiple small &/or large vessel with lacunar infarcts
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- ## Nuclear Medicine Findings
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- F-18 FDG PET/CT
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- Glucose hypometabolism in multifocal (scattered) pattern of cortical with subcortical regions
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- Altered pattern depending on subtype (i.e., multifocal small vessel infarcts vs. large territory infarcts)
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- Hypometabolism often in clinically affected areas: Correlates with other clinical findings
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- May be used in differential diagnosis between VaD and Alzheimer disease (AD)
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- AD pattern: Hypometabolism in bilateral parietotemporal with posterior cingulate cortices: Extension to frontal/occipital
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- VaD may have hypometabolism in subcortical areas, which are spared in AD
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- Amyloid PET without gray matter amyloid deposition
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- May be used in differential diagnosis between VaD and AD
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- SPECT with Tc-99m HMPAO or Tc-99m ECD shows similar asymmetric decreased perfusion
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- ## Imaging Recommendations
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- ### Best imaging tool
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- F-18 FDG PET may aid in differential diagnosis
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- MR to see vascular insults and look for potential reversible causes of dementia
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- ### Protocol advice
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- F-18 FDG PET
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- Patient preparation
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- Patient should fast, stop IV fluids containing dextrose, stop parenteral feeding for 4-6 hours
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- Blood sugar should be < 150-200 mg/dL
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- Patient should be placed in quiet, dimly lit room prior to and after injection for 30 min
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- Radiopharmaceutical: 5-15 mCi F-18 FDG
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- Dosimetry: Urinary bladder receives largest dose
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- Image acquisition: 30-60 min after injection
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# DIFFERENTIAL DIAGNOSIS
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- [Alzheimer Disease](/document/alzheimer-disease/2aad3ac4-44fd-43e5-8e50-a86987483af3)
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- Early F-18 FDG hypometabolism in parietotemporal and posterior cingulate cortices
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- Later changes include frontal lobe
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- Positive amyloid PET
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- Atrophy of medial temporal lobe structures on MR/CT
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- ## Dementia With Lewy Bodies
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- Commonly presents with hallucinations, sleep disturbances, and parkinsonian motor features
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- F-18 FDG PET hypometabolism in occipital cortex or striatal loss of dopamine transport
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- [Normal-Pressure Hydrocephalus](/document/normal-pressure-hydrocephalus/834ccc3e-2116-4295-8408-0ac9a06bd2ff)
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- Dilated ventricles on CT or MR
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- Metabolic or perfusion reductions in lateral cortex (frontal and parietal), separation of caudate heads
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- Reduced activity in periventricular WM and ventricular regions > expected for age
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- ## Mixed Dementia
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- Characteristic features of > 1 type of dementia
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- Commonly includes AD and another pathology (such as VaD)
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- ## Frontotemporal Dementia
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- Commonly presents with personality and behavioral changes
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- Atroph of frontal and anterior temporal lobes
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- F-18 FDG PET hypometabolism primarily in frontal and anterior temporal lobes
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- [Huntington Disease](/document/huntington-disease/4abd9bb7-7d47-4308-a71f-9985fdb23c2c)
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- Major reduction in basal ganglia metabolism and perfusion (worse in caudate)
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- Cortical reductions (late)
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- ## Posttraumatic Dementia
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- Pattern of abnormality on functional imaging variable: Depends on severity, directional forces at injury
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- Chronic subdural may cause significant asymmetry
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- Deceleration injury may cause anterior frontal and temporal tip reductions
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- Atrophic pattern may occur; worse with increasing severity of injury
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- Focal reduction correlates with encephalomalacia and other cortical abnormalities on CT or MR
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- Basal ganglia, thalamic abnormalities may be present
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- ## Drug-Related Dementia
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- Cocaine and amphetamine abuse: Random small focal defects throughout brain
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- Swiss cheese pattern on FDG PET and SPECT
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- Alcohol abuse: May demonstrate frontal lobe decrease
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- ## Autoimmune Dementia
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- Vasculitis pattern in systemic lupus; frontal watershed abnormalities
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- Small cortical defects mainly frontal lobe
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- [Creutzfeldt-Jakob Disease](/document/creutzfeldt-jakob-disease-cjd/e1b27954-6591-4bb0-a659-b13790492620)
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- Rapidly fatal, prion-related disease with impairments in cognition and behavioral changes
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- Diffusion-weighted imaging hyperintensity in striatum, cingulum, and neocortex
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- ## Causes of Reversible Dementia
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- Normal-pressure hydrocephalus, vitamin B12 deficiency, hypothyroidism, depression, mass lesions, infections (neurosyphilis, HIV), trauma (chronic subdurals)
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# PATHOLOGY
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- ## General Features
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- Vascular-related lesions leading to loss of brain function
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- Chronic small vessel insults > large vessel infarcts
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- Areas of infarction (focal or multifocal) with associated atrophy
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- ## Risk Factors
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- History of myocardial infarction/coronary artery disease, stroke/transient ischemic attack (TIA)
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- Atherosclerosis, hypertension, hyperlipidemia, atrial fibrillation
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- Diabetes, obesity, smoking, advanced age
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# CLINICAL ISSUES
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- ## Presentation
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- Significant heterogeneity in clinical presentation depending on location, type, and size of vascular lesion
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- Impairment in at least 1 cognitive domain leading to decline in functional status
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- Executive function and attention more commonly initially affected than in AD
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- Slow motor/information processing
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- Language difficulties
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- Changes in behavior and personality
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- Depression and anxiety
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- Other: Seizures, bladder incontinence, gait disturbance, and additional focal abnormalities
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- Overt disease: Cognitive impairment due to clinically evident vascular event [large territory infarct(s)]
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- > 60% of stroke patients (dementia in ~ 30% of cases)
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- Covert disease: Insidious process of vascular insults (clinically silent with extensive lacunar infarcts)
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- ## Demographics
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- 2nd most common cause of dementia after AD
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- > 10% of dementia cases
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- Age: Incidence increases with age
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- Sex: M > F
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# DIAGNOSTIC CHECKLIST
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- ## Image Interpretation Pearls
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- Heterogeneous F-18 FDG activity without any specific pattern suggests VaD
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- Lesions can include basal ganglia and other areas typically spared in other diseases
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- MR correlation helpful
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18eb7ef1-b90d-42fa-ae9c-fe185e01420c
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## References
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# Selected References
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1. Minoshima S et al: FDG PET imaging evaluation of neurodegenerative dementias. In Cross DJ et al: Molecular Imaging of Neurodegenerative Disorders. Springer. 57-72, 2023
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1. [Chang Wong E et al: Vascular cognitive impairment and dementia. Continuum (Minneap Minn). 28(3):750-80, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35678401%5Bpmid%5D)
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1. [Minoshima S et al: (18)F-FDG PET imaging in neurodegenerative dementing disorders: insights into subtype classification, emerging disease categories, and mixed dementia with copathologies. J Nucl Med. 63(Suppl 1):2S-12S, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35649653%5Bpmid%5D)
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1. [Nestor PJ et al: Clinical utility of FDG-PET for the differential diagnosis among the main forms of dementia. Eur J Nucl Med Mol Imaging. 45(9):1509-25, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29736698%5Bpmid%5D)
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1. [Sawyer DM et al: Top-down systematic approach to interpretation of FDG-PET for dementia. Clin Nucl Med. 43(6):e212-4, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29659399%5Bpmid%5D)
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1. [Heiss WD et al: PET imaging in the differential diagnosis of vascular dementia. J Neurol Sci. 322(1-2):268-73, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23043907%5Bpmid%5D)
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1. [Román G et al: Contribution of neuroimaging to the diagnosis of Alzheimer's disease and vascular dementia. Arch Med Res. 43(8):671-6, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23142262%5Bpmid%5D)
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## Images
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### Selected Images
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*Axial graphic shows multifocal infarcts involving the cortical gray matter and subcortical white matter bilaterally.*
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*Axial graphic shows multifocal infarcts involving the cortical gray matter and subcortical white matter bilaterally.*
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*Axial graphic shows multifocal infarcts involving the cortical gray matter and subcortical white matter bilaterally.*
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*Coronal FLAIR MR of a 72-year-old woman demonstrates FLAIR signal abnormality in the periventricular and subcortical white matter (leukoaraiosis). This finding is consistent with a small vessel ischemic etiology.*
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*Surface mapping of an FDG PET scan performed in a 96-year-old man demonstrates multiple areas of significant cortical abnormality in glucose metabolism, including the left frontal lobe <img src='img/arrows/CS.png'/>, the right occipital lobe <img src='img/arrows/CC.png'/> and the cingulate gyrus <img src='img/arrows/CO.png'/>, consistent with multiinfarct dementia.*
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*Axial F-18 FDG PET in a patient presenting with dementia shows more unilateral areas of hypometabolism <img src='img/arrows/WS.png'/> and globally decreased F-18 FDG uptake, also consistent with vascular dementia (VaD).*
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### Additional Images
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*Alzheimer dementia is shown. Note the parietal and posterior temporal reductions <img src='img/arrows/WS.png'/> and sparing of occipital and frontal lobes.*
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*Frontotemporal dementia (FTD) is shown. Note the frontal and anterior temporal reductions <img src='img/arrows/WS.png'/> and sparing of parietal, posterior temporal, and occipital regions.*
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*Axial FDG PET in a patient with Lewy body disease shows parietal and posterior temporal reduction similar to Alzheimer disease (AD) <img src='img/arrows/WS.png'/>, but occipital cortex <img src='img/arrows/WO.png'/> is also involved.*
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*Surface-rendered Tc-99m ECD SPECT in the same patient demonstrates severe reductions of parietal, temporal <img src='img/arrows/WS.png'/>, and occipital cortex <img src='img/arrows/WO.png'/>.*
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*Axial FDG PET in a case of autopsy-proven Creutzfeldt-Jakob disease (CJD) shows multiple cortical defects <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT shows a pattern similar to AD <img src='img/arrows/WS.png'/>; however, clinical course was that of a rapid progressive dementia ending in death within 12 months of onset.*
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*Axial Tc-99m ECD SPECT in a patient with clinical progressive supranuclear palsy (PSP) presentation shows severe frontal lobe decrease <img src='img/arrows/WO.png'/> and mild reduction in caudate heads <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT demonstrates severe frontal decrease relative to parietal and occipital cortex <img src='img/arrows/WS.png'/>.*
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*Axial Tc-99m ECD SPECT (baseline) in a patient with early FTD shows frontal atrophy and mild reduction in perfusion <img src='img/arrows/WS.png'/>.*
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*Axial Tc-99m ECD SPECT in the same patient (18 months post baseline) demonstrates significant decrease of frontal lobe activity from baseline study <img src='img/arrows/WS.png'/>, consistent with worsening dementia.*
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*Surface-rendered Tc-99m ECD SPECT of the same patient (baseline) demonstrates mild frontal lobe findings <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT 18 months post baseline demonstrates worsening <img src='img/arrows/WS.png'/>.*
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*Axial FDG PET in a patient with Huntington disease and mild dementia shows severe reduction in basal ganglia <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT in the same patient shows mild frontal <img src='img/arrows/WO.png'/> and parietal reductions <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT in a patient with normal pressure hydrocephalus (NPH) shows severe frontal and parietal defects <img src='img/arrows/WS.png'/> with preservation of vertex <img src='img/arrows/WO.png'/>.*
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*In-111 DTPA cisternogram (24 hours) in the same patient shows abnormal ventricular activity <img src='img/arrows/BS.png'/>.*
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*Axial Tc-99m ECD SPECT in a patient with multiinfarct dementia shows multiple infarcts of the frontal and parietal cortex <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT in the same patient shows asymmetric cortical findings <img src='img/arrows/WS.png'/>.*
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*Surface-rendered Tc-99m ECD SPECT in a patient with history of cocaine abuse and early dementia shows diffuse cortical findings.*
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*Surface-rendered Tc-99m ECD SPECT in a patient with history of methamphetamine abuse and early dementia is shown.*
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