Enlarged Sulci, Generalized



Enlarged Sulci, Generalized


Anne G. Osborn, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Aging Brain, Normal


  • Dementias



    • Alzheimer Dementia


    • Vascular Dementia


    • Dementia with Lewy Bodies


    • Frontotemporal Dementia


  • Chronic Alcoholic Encephalopathy


  • HIV Encephalitis


Less Common



  • Chronic Hepatic Encephalopathy


  • Remote Generalized Insult



    • Trauma


    • Hypoxic Ischemic Encephalopathy


    • Meningitis


    • Encephalitis (Miscellaneous)


    • Multiple Sclerosis (Longstanding)


    • Radiation and Chemotherapy


    • Other Toxic/Metabolic Insults


  • Enlarged Subarachnoid Spaces (Benign Macrocrania of Infancy)


Rare but Important



  • Steroids


  • Volume Loss Secondary to Nutrition or Hydration Status


  • Miscellaneous Neurodegenerative Disorders



    • Corticobasal Degeneration


    • Parkinson Disease


    • Huntington Disease


    • Multiple System Atrophy


  • Creutzfeldt-Jakob Disease (CJD)


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Some age-related volume loss (especially cortical) normal


  • Location helpful



    • Generalized or disproportionately affecting some parts of brain more than others?


    • Parieto-temporal/hippocampal (Alzheimer), frontotemporal (FTD or Lewy body disease) vs. parieto-occipital (Heidenhain variant of CJD)


  • Clinical information helpful



    • History of trauma, drug abuse, stroke, infection


    • Dehydration, steroids may cause temporary sulcal enlargement


    • Metabolic/demyelinating disorders (inherited or acquired, longstanding) may cause volume loss, sulcal enlargement


Helpful Clues for Common Diagnoses



  • Aging Brain, Normal



    • White matter volume decreases


    • Mild/moderate ventricular, sulcal enlargement


    • Thin periventricular hyperintense rim


    • Scattered white matter hyperintensities increase with age, normal


    • “Black dots” on GRE/SWI are NOT normal



      • Chronic hypertensive encephalopathy


      • Cerebral amyloid angiopathy


  • Dementias



    • Evaluate for other treatable (potentially treatable) causes of dementia (e.g., repeated trauma with subdural hematoma)



      • Endocrinopathy (e.g., hypothyroidism)


      • Alcohol/drug abuse


      • Depression (“pseudodementia”)


    • General imaging findings



      • Differentiation solely on basis of CT, standard MR difficult


      • PET, fMRI helpful


    • Alzheimer Dementia



      • Temporal (especially hippocampal), parietal atrophy


      • Hypometabolic areas, perfusion deficits


    • Vascular Dementia



      • Second most common dementia


      • Volume loss, multiple chronic infarcts, lacunes


      • Multifocal white matter disease, often confluent (arteriolosclerosis)


    • Dementia with Lewy Bodies



      • Visual/auditory hallucinations, delusions


      • Entire brain hypometabolic (including visual cortex, cerebellum)


    • Frontotemporal Dementia



      • Anterior frontotemporal atrophy


      • “Knife-like” gyri


      • Up to 40% familial (tau mutations)


  • Chronic Alcoholic Encephalopathy



    • Generalized & cerebellar (superior vermian) atrophy


    • Hyperintense basal ganglia on T1WI suggests chronic hepatic encephalopathy


    • Polydrug abuse common


    • Methanol less common; causes hemorrhagic putaminal necrosis



  • HIV Encephalitis



    • Most common imaging finding in brains of HIV/AIDS patients


    • Diffuse atrophy, “hazy” white matter hyperintensity


Helpful Clues for Less Common Diagnoses

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Enlarged Sulci, Generalized

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