Question 1

Q: A 72-year-old woman is brought in by her daughter for progressive confusion over 4 weeks, 8 kg of unintentional weight loss over 3 months, and new-onset urinary incontinence. She has no history of psychiatric illness. Medications include amlodipine and aspirin. On examination, she is afebrile; she scores 19/30 on the MMSE. Gait is broad-based and magnetic in quality. Neurological exam shows no focal deficits and no papilledema. CBC, CMP, TSH, B12, and RPR are all within normal limits. The image shown is from her MRI brain. Which of the following diagnoses is most consistent with the clinical presentation and imaging finding?

Normal pressure hydrocephalus. ***Normal pressure hydrocephalus*** - The patient presents with the classic clinical triad of **urinary incontinence** ("wet"), **cognitive decline** ("wacky"), and a **broad-based magnetic gait** ("wobbly") characteristic of this condition. - Imaging typically reveals **ventriculomegaly** disproportionate to cortical sulfur atrophy, often measured by an **Evans' index** greater than 0.3. *Alzheimer dementia with comorbid depression* - While it causes cognitive decline, **gait impairment** and **urinary incontinence** are typically late-stage findings rather than early or presenting symptoms. - Neuroimaging usually shows asymmetric **hippocampal atrophy** and prominent cortical sulcal widening rather than isolated ventricular enlargement. *Chronic subdural hematoma* - Often presents with insidious headache and fluctuating levels of consciousness, but usually follows a history of **head trauma** or occurs in patients on anticoagulants. - MRI would demonstrate a **crescent-shaped** fluid collection compressing the brain parenchyma, which is not described in the ventricular-focused findings. *Frontotemporal dementia* - Primarily characterized by early **personality changes**, disinhibition, or language deficits rather than magnetic gait abnormalities. - Imaging typically highlights focal **frontal and temporal lobe atrophy** (the "knife-blade" sign) rather than generalized ventricular enlargement. *Creutzfeldt-Jakob disease* - This condition features a **rapidly progressive dementia** (over weeks to months) often accompanied by **myoclonus** and ataxia. - Characteristic MRI findings include **diffusion restriction** in the cortex (**cortical ribboning**) or basal ganglia, which differs from the findings of normal pressure hydrocephalus.

Question

A 72-year-old woman is brought in by her daughter for progressive confusion over 4 weeks, 8 kg of unintentional weight loss over 3 months, and new-onset urinary incontinence. She has no history of psychiatric illness. Medications include amlodipine and aspirin. On examination, she is afebrile; she scores 19/30 on the MMSE. Gait is broad-based and magnetic in quality. Neurological exam shows no focal deficits and no papilledema. CBC, CMP, TSH, B12, and RPR are all within normal limits. The image shown is from her MRI brain. Which of the following diagnoses is most consistent with the clinical presentation and imaging finding?

Accepted Answer

Normal pressure hydrocephalus

Answer

Alzheimer dementia with comorbid depression

Answer

Chronic subdural hematoma

Answer

Frontotemporal dementia

Answer

Creutzfeldt-Jakob disease

Clinical Reasoning — MCQs

Clinical Reasoning — MCQs

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