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A 69-year-old man with a 10-year history of localisation-related epilepsy with secondary generalisation, and a 1-year history of right occipital haemorrhage presented with cognitive impairment, insomnia, visual hallucinosis and shortened stride. Examination suggested encephalopathy with subtle appendicular myoclonus and left hand postural and classical rest tremor, asymmetrical bradykinesia, neck and limb rigidity and left-sided neglect. Saccadic eye movements were entirely normal for approximately 5 years of follow-up. Sagittal T1 imaging (see figure 1A) demonstrated midbrain atrophy suggestive of the ‘hummingbird’ sign of Progressive Supranuclear Palsy (PSP) in the context of diffuse hemispheric foci of susceptibility artefact (see figure 1B) secondary to microhaemorrhages from cerebral amyloid angiopathy (CAA). 123I-Ioflupane single-photon emission computed tomography (SPECT) (DaTSCAN) was performed and demonstrated significant reduction in radiotracer uptake in the striatum bilaterally. Significant reduction in radiotracer uptake in the posterior striatum, particularly on the right was noted. The DaTSCAN was graded as upper range of grade 2 out of 3 by qualitative assessment according to the Catafau …
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