Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499 Accepted: May 6, 2014 Published online: July 2, 2014
© 2014 S. Karger AG, Basel 1420–8008/14/0386–0281$39.50/0 www.karger.com/dem
Original Research Article
Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey Leo Boelaarts a
Philip Scheltens b
Jos de Jonghe a
a Department
of Geriatric Medicine, Medical Center Alkmaar, Alkmaar, and of Neurology and Alzheimer Center, VU University Medical Center, Amsterdam, The Netherlands
b Department
Key Words Outpatient memory clinics · MRI · Radiological assessment · Dementia Abstract Background: In the Netherlands, dementia syndromes are diagnosed in specialized memory outpatient clinics (MC). Many radiologists are not trained to assess magnetic resonance imaging (MRI) scans with respect to possible radiological changes that may indicate neurodegenerative disease. Methods: This is a cross-sectional descriptive study. A survey was sent to all Dutch MC and included questions as to how MRI scans are assessed by radiologists and how these assessments are used in the diagnostic process. Results: In most MC, radiologists report on typical Alzheimer pathology and large vessel disease. Small vessel disease and other anatomical changes signifying neurodegenerative disease frequently are not assessed. In the majority of MC, the radiological assessment is not standardized, and physicians assess MRI for themselves to use this information to discuss the consensus diagnosis subsequently. Conclusion: MRI assessment by radiologists in Dutch MC probably underestimates the presence of cerebrovascular and neurodegenerative disease. The validity of standardized assessment protocols in routine clinical practice deserves further study, as the implementation of standardization outside research settings could improve diagnostic accuracy. © 2014 S. Karger AG, Basel
Introduction
International guidelines recommend the use of brain imaging techniques in diagnosing dementia syndromes [1–4]. Magnetic resonance imaging (MRI) is a sensitive tool to study brain anatomy [5]. This technique is used to exclude treatable causes but may also point to hallmarks of brain disease [6]. L. Boelaarts, MD, MSc Department of Geriatric Medicine Medical Centre Alkmaar PO Box 501, NL–1800 AM Alkmaar (The Netherlands) E-Mail l.boelaarts @ mca.nl
282
Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
In research settings, visual rating scales have been developed to rate cerebral atrophy and white matter changes (WMC) in dementia patients’ MRIs [5]. It is unknown to what degree these techniques are used in everyday medical practice and what effect the use of these instruments has on the sensitivity and specificity of the clinical diagnosis in routine memory clinic practice. In the Netherlands, GPs usually refer patients with cognitive disorders to memory outpatient clinics (MC) that usually are located outside tertiary referral centers. A 2009 survey of Dutch MC reported that more than 80% of the patients undergo neuroimaging [7]. Apparently, broad consensus exists on the usefulness of neuroimaging as a diagnostic aid. However, radiologists not necessarily have expertise in neurodegenerative diseases. We performed a survey among Dutch MC to evaluate how MR images are read, how often rating scales are used and how clinicians use these results in everyday practice. Methods This is a cross-sectional descriptive study on how MRI is assessed and used in the diagnostic process of cognitive disorders in Dutch MC. We focused on the use of MRI only. A survey was sent to coordinating physicians of MC who participated in the third Dutch MC survey in 2009 [7]. Survey questions elicited information on the type of MC setting, the use of a diagnostic program protocol, availability of MRI and biographical data of the patients. The participants were asked whether they thought radiologists reported on the presence of infarcts, lacunae in the cortex and basal ganglia or microbleeds (MB), whether visual rating scales were used to assess medial temporal lobe atrophy (MTA), global cortical atrophy (GCA), parietal atrophy (PA) and the Fazekas score for WMC, and whether they felt radiologists reported on anatomical changes suggestive of frontotemporal lobe atrophy (FTLD) and progressive supranuclear palsy (PSP). Other issues that comprised this survey were whether the radiologists also mentioned a possible etiology in their report, whether they differed in this and whether they were present at the multidisciplinary team meeting. Finally, we asked whether the physicians assessed the MRIs for themselves and use this assessment or the radiology report in their discussion on the consensus diagnosis. After 3 months, a second invitation to participate in the study was sent to the coordinating physicians who had not yet responded. Cerebral and regional atrophy may indicate neurodegenerative disease. Global cerebral atrophy can be assessed using the four-step GCA scale ranging from no atrophy, score 0, to knife-blade atrophy, score 3 [8]. In everyday practice, MTA can be assessed using the Scheltens visual rating scale. This scale can be easily learned to use and correlates well with volumetry [9–11]. The score on the MTA scale has a diagnostic dimension [10, 12–19]. A score of more than 2 in patients under the age of 75 and a score of more than 3 over the age of 75 is suggestive of Alzheimer’s disease (AD). In the PA four-point scale, sulcal widening and gyral shrinkage of the precuneus, the posterior cingulate sulcus and the parieto-occipital sulcus are assessed. This scale proved to be a reliable tool in the discrimination by structural imaging of Alzheimer’s dementia and other dementias [20]. The assessment of the extent of WMC and the localization of lacunar infarcts is required to diagnose vascular dementia (VaD) [21, 22]. There are a number of WMC rating scales [23], the simplest being the Fazekas scale [24]. A score of 0 or 1, representing punctuate small WMC, is considered normal. A score of 2, representing early confluent WMC, is deemed abnormal in subjects under the age of 70 years. A score of 3, representing confluent WMC, predicts a poor outcome of cognition and survival in all age categories [25]. The statistical analysis was performed using SPSS version 20. The results are presented as absolute numbers or percentages. The χ2 statistic was used to study the relationship between variables.
Results
A total of 88 surveys were sent, of which 61% were returned. Forty-three of 54 MC are situated in a general or university hospital. Other locations are outpatient clinics of psychiatric hospitals and nursing homes.
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Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
Table 1. Number of MC where radiologists use visual rating scales and report on other brain pathology
Scale/assessment
Hospitals, n (n = 54)
%
MTA GCA PA WMC Fazekas score Cortical lacunae, n Lacunae in DGM, n MB, n Presence of large vessel infarcts Radiological changes suggestive of FTLD Radiological changes suggestive of PSP
42 42 21 31 45 35 23 47 8 8
86 86 43 63 92 71 47 96 16 16
DGM = Deep gray matter.
Almost all MC use a diagnostic program protocol. In 89% of the MC, an MRI scan is available. Geriatric medicine or neurology is the coordinating specialty in most MC. In the former, the mean age of the patients is 76.2 years (n = 24, SD 3.8), and in the latter, it is 70.8 years (n = 15, SD 4.9). Only MTA, GCA, number of cortical lacunae and large vessel infarcts are assessed in more than 80% of the MC (table 1). In 35% of the cases, radiologists mention a possible etiology for their findings. In 78% of the MC, some radiologists do and others do not mention an etiology. In 6% of the cases, radiologists are present at the multidisciplinary team meeting. In 85% of the MC, physicians assess MRIs for themselves, and 81% of these assessments are used in the discussion on the diagnosis. When radiologists do not suggest an etiology, physicians more often assess MRIs for themselves (p < 0.001) and use this information in the discussion on the consensus diagnosis (p = 0.002). Discussion
In this study, we surveyed the way radiologists assess MRIs of MC patients, how they report and how multidisciplinary MC teams use these findings in their consensus discussions. The main study finding is that radiologists frequently do not report on specific signs of cerebrovascular disease. The strength of this study is the relatively high response rate, indicating that the data are representative for Dutch MC. The study results are remarkable. We found that lacunae in the deep gray matter are not reported in almost one third of the cases, and the Fazekas score is frequently not used to report on WMC. Cerebrovascular disease is common in the population over 60 years of age. WMC are prevalent in MC patients [26–28], and the severity of WMC corresponding to a Fazekas score of 2 or 3 is associated with VaD. These findings raise concern as the outcome of cerebrovascular disease can be attenuated by treating vascular risk factors. Few if any studies have examined how radiology reports are used in MC. The 2009 Dutch MC monitor reports on the number of MC, their setting and organization, the nature of diagnoses and which diagnostic tools are used. However, this is the first study to report in detail on the way MRI is used in the diagnostic process in Dutch MC. Other findings of this study are the frequent use of visual rating scales to assess MTA and GCA. Moreover, in less than half of the MC, PA and MB are radiologically assessed. PA typically signifies the presence of AD, especially in younger patients [20]. The presence of MB is considered to be a pathological phenomenon [29–32], as the presence of more than 5 MB is
284
Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
associated with a poor neuropsychological test performance [33]. Both MB and PA probably are assessed less frequent as these signs have been reported to be of use in the assessment of MRI only relatively recently. Furthermore, few radiologists report on neuroanatomical changes that may suggest the presence of FTLD or PSP. This may be explained by the lack of experience of radiologists with these entities. Consequently, this finding could mean that patients may not receive appropriate care. Finally, radiologists frequently do not report in a standardized way and do not discuss their assessment of MRIs in the multidisciplinary meeting. In the majority of the cases, physicians assess the MRIs for and use this information in discussing the consensus diagnosis. It is unknown whether the assessments of MC physicians can compensate for the underreporting of cerebrovascular disease and non-Alzheimer pathology by radiologists. A potential limitation of our study is that we asked the coordinating specialists to give a best estimation of the issues we raised in our questions. We cannot exclude that this leads to biased responses that exaggerate the main finding of this study or are an underestimation of the assessment of the typical Alzheimer pathology and large vessel disease. We thought it would not be feasible for the coordinating specialists to give quantified data where the response rate would probably be much lower. In conclusion, in Dutch MC, MTA and GCA are frequently assessed using visual scales. This may be considered a positive outcome as it reflects some standardization in radiology reports. However, VaD and non-Alzheimer pathology probably are underdiagnosed, but this may be improved by the use of a standardized protocol by radiologists to assess and report on this issues. We feel that the effect of using a standardized assessment protocol on the sensitivity and specificity of clinical diagnoses in MC outside research settings should be an issue for future study. Acknowledgment
The authors would like to thank all participants in this survey and Mrs. Luyckx for her invaluable assistance and secretarial work.
References 1
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Bosscher L, Scheltens P: MRI of the medial temporal lobe for the diagnosis of Alzheimer’s disease; in Qizilbash N, Schneider LS, Chui H, Tariot P, Brodaty H, Kaye J, Erkinjuntti T (eds): Evidence-Based Dementia Practice. Oxford, Blackwell Publishing, 2002, pp 154–162. Barber R, Gholkar A, Scheltens P, Ballard C, McKeith IG, O’Brien JT: Medial temporal lobe atrophy on MRI in dementia with Lewy bodies. Neurology 1999;52:1153–1158. Boutet C, Chupin M, Colliot O, Sarazin M, Mutlu G, Drier A, Pellot A, Dormont A, Lehericy S; Alzheimer’s Disease Neuroimaging Initiative: Is radiological evaluation as good as computer-based volumetry to assess hippocampal atrophy in Alzheimer’s disease? Neuroradiology 2012;54:1321–1330. DeCarli C, Frisoni GB, Clark CM, Harvey D, Grundman M, Petersen RC, Thal LJ, Jin S, Jack CR Jr, Scheltens P; Alzheimer’s Disease Cooperative Study Group: Qualitative estimates of medial temporal atrophy as a predictor of progression from mild cognitive impairment to dementia. Arch Neurol 2007;64:108–115. Geroldi C, Rossi R, Calvagna C, Testa C, Bresciani L, Binetti G, Zanetti O, Frisoni GB: Medial temporal atrophy but not memory deficit predicts progression to dementia in patients with mild cognitive impairment. J Neurol Neurosurg Psychiatry 2006;77:1219–1222. Korf ES, Wahlund LO, Visser PJ, Scheltens P: Medial temporal lobe atrophy on MRI predicts dementia in patients with mild cognitive impairment. Neurology 2004;63:94–100. Launer LJ, Scheltens P, Lindeboom J, Barkhof F, Weinstein HC, Jonker C: Medial temporal lobe atrophy in an open population of very old persons: cognitive, brain atrophy, and sociomedical correlates. Neurology 1995; 45:747–752. Visser PJ, Scheltens P, Verhey FR, Schmand B, Launer LJ, Jolles J, Jonker C: Medial temporal lobe atrophy and memory dysfunction as predictors for dementia in subjects with mild cognitive impairment. J Neurol 1999; 246:477–485. 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Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA: MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. Am J Roentgenol 1987;149:351–356. Inzitari D, Pracucci G, Poggesi A, Carlucci G, Barkhof F, Chabriat H, Erkinjuntti T, et al: Changes in white matter as determinant of global functional decline in older independent outpatients: three year follow-up of LADIS (leukoaraiosis and disability) study cohort. BMJ 2009;339:b2477. de Leeuw FE, Groot JC, Achten E, Oudkerk M, Ramos LM, Heijboer R, Hofman A, Jolles J, van Gijn J, Breteler MM: Prevalence of cerebral white matter lesions in elderly people: a population based magnetic resonance imaging study. J Neurol Neurosurg Psychiatry 2001;70:9–14. Dubois MF, Hebert R: The incidence of vascular dementia in Canada: a comparison with Europe and East Asia. Neuroepidemiology 2001;20:179–187. Longstreth WT Jr, Manolio TA, Arnold A, Burke GL, Bryan N, Jungreis CA, Enright PL, O’Leary D, Fried L: Clinical correlates of white matter findings on cranial magnetic resonance imaging of 3,301 elderly people. The Cardiovascular Health Study. Stroke 1996;27:1274–1282. Goos JD, Kester MI, Barkhof F, Klein M, Blankenstein MA, Scheltens P, van der Flier WM: Alzheimer’s disease patients with multiple microbleeds; relation with CSF biomarkers and cognition. Stroke 2009;40:3455–3460. Poels MM, Ikram MA, van der Lugt A, Hofman A, Krestin GP, Breteler MM, Vernooij MW: Incidence of cerebral microbleeds in the general population: the Rotterdam Scan Study. Stroke 2011;42:656–661. Poels MM, Ikram MA, Vernooij MW: Improved MR imaging detection of cerebral microbleeds more accurately identifies persons with vasculopathy. Am J Neuroradiol 2012;33:1553–1556. Scheltens P, Goos J: Microbleeds in dementia – singing a different ARIA. Nat Rev Neurol 2012;10:68–70. 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© 2014 S. Karger AG, Basel 1420–8008/14/0386–0281$39.50/0 www.karger.com/dem
Original Research Article
Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey Leo Boelaarts a
Philip Scheltens b
Jos de Jonghe a
a Department
of Geriatric Medicine, Medical Center Alkmaar, Alkmaar, and of Neurology and Alzheimer Center, VU University Medical Center, Amsterdam, The Netherlands
b Department
Key Words Outpatient memory clinics · MRI · Radiological assessment · Dementia Abstract Background: In the Netherlands, dementia syndromes are diagnosed in specialized memory outpatient clinics (MC). Many radiologists are not trained to assess magnetic resonance imaging (MRI) scans with respect to possible radiological changes that may indicate neurodegenerative disease. Methods: This is a cross-sectional descriptive study. A survey was sent to all Dutch MC and included questions as to how MRI scans are assessed by radiologists and how these assessments are used in the diagnostic process. Results: In most MC, radiologists report on typical Alzheimer pathology and large vessel disease. Small vessel disease and other anatomical changes signifying neurodegenerative disease frequently are not assessed. In the majority of MC, the radiological assessment is not standardized, and physicians assess MRI for themselves to use this information to discuss the consensus diagnosis subsequently. Conclusion: MRI assessment by radiologists in Dutch MC probably underestimates the presence of cerebrovascular and neurodegenerative disease. The validity of standardized assessment protocols in routine clinical practice deserves further study, as the implementation of standardization outside research settings could improve diagnostic accuracy. © 2014 S. Karger AG, Basel
Introduction
International guidelines recommend the use of brain imaging techniques in diagnosing dementia syndromes [1–4]. Magnetic resonance imaging (MRI) is a sensitive tool to study brain anatomy [5]. This technique is used to exclude treatable causes but may also point to hallmarks of brain disease [6]. L. Boelaarts, MD, MSc Department of Geriatric Medicine Medical Centre Alkmaar PO Box 501, NL–1800 AM Alkmaar (The Netherlands) E-Mail l.boelaarts @ mca.nl
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Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
In research settings, visual rating scales have been developed to rate cerebral atrophy and white matter changes (WMC) in dementia patients’ MRIs [5]. It is unknown to what degree these techniques are used in everyday medical practice and what effect the use of these instruments has on the sensitivity and specificity of the clinical diagnosis in routine memory clinic practice. In the Netherlands, GPs usually refer patients with cognitive disorders to memory outpatient clinics (MC) that usually are located outside tertiary referral centers. A 2009 survey of Dutch MC reported that more than 80% of the patients undergo neuroimaging [7]. Apparently, broad consensus exists on the usefulness of neuroimaging as a diagnostic aid. However, radiologists not necessarily have expertise in neurodegenerative diseases. We performed a survey among Dutch MC to evaluate how MR images are read, how often rating scales are used and how clinicians use these results in everyday practice. Methods This is a cross-sectional descriptive study on how MRI is assessed and used in the diagnostic process of cognitive disorders in Dutch MC. We focused on the use of MRI only. A survey was sent to coordinating physicians of MC who participated in the third Dutch MC survey in 2009 [7]. Survey questions elicited information on the type of MC setting, the use of a diagnostic program protocol, availability of MRI and biographical data of the patients. The participants were asked whether they thought radiologists reported on the presence of infarcts, lacunae in the cortex and basal ganglia or microbleeds (MB), whether visual rating scales were used to assess medial temporal lobe atrophy (MTA), global cortical atrophy (GCA), parietal atrophy (PA) and the Fazekas score for WMC, and whether they felt radiologists reported on anatomical changes suggestive of frontotemporal lobe atrophy (FTLD) and progressive supranuclear palsy (PSP). Other issues that comprised this survey were whether the radiologists also mentioned a possible etiology in their report, whether they differed in this and whether they were present at the multidisciplinary team meeting. Finally, we asked whether the physicians assessed the MRIs for themselves and use this assessment or the radiology report in their discussion on the consensus diagnosis. After 3 months, a second invitation to participate in the study was sent to the coordinating physicians who had not yet responded. Cerebral and regional atrophy may indicate neurodegenerative disease. Global cerebral atrophy can be assessed using the four-step GCA scale ranging from no atrophy, score 0, to knife-blade atrophy, score 3 [8]. In everyday practice, MTA can be assessed using the Scheltens visual rating scale. This scale can be easily learned to use and correlates well with volumetry [9–11]. The score on the MTA scale has a diagnostic dimension [10, 12–19]. A score of more than 2 in patients under the age of 75 and a score of more than 3 over the age of 75 is suggestive of Alzheimer’s disease (AD). In the PA four-point scale, sulcal widening and gyral shrinkage of the precuneus, the posterior cingulate sulcus and the parieto-occipital sulcus are assessed. This scale proved to be a reliable tool in the discrimination by structural imaging of Alzheimer’s dementia and other dementias [20]. The assessment of the extent of WMC and the localization of lacunar infarcts is required to diagnose vascular dementia (VaD) [21, 22]. There are a number of WMC rating scales [23], the simplest being the Fazekas scale [24]. A score of 0 or 1, representing punctuate small WMC, is considered normal. A score of 2, representing early confluent WMC, is deemed abnormal in subjects under the age of 70 years. A score of 3, representing confluent WMC, predicts a poor outcome of cognition and survival in all age categories [25]. The statistical analysis was performed using SPSS version 20. The results are presented as absolute numbers or percentages. The χ2 statistic was used to study the relationship between variables.
Results
A total of 88 surveys were sent, of which 61% were returned. Forty-three of 54 MC are situated in a general or university hospital. Other locations are outpatient clinics of psychiatric hospitals and nursing homes.
283
Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
Table 1. Number of MC where radiologists use visual rating scales and report on other brain pathology
Scale/assessment
Hospitals, n (n = 54)
%
MTA GCA PA WMC Fazekas score Cortical lacunae, n Lacunae in DGM, n MB, n Presence of large vessel infarcts Radiological changes suggestive of FTLD Radiological changes suggestive of PSP
42 42 21 31 45 35 23 47 8 8
86 86 43 63 92 71 47 96 16 16
DGM = Deep gray matter.
Almost all MC use a diagnostic program protocol. In 89% of the MC, an MRI scan is available. Geriatric medicine or neurology is the coordinating specialty in most MC. In the former, the mean age of the patients is 76.2 years (n = 24, SD 3.8), and in the latter, it is 70.8 years (n = 15, SD 4.9). Only MTA, GCA, number of cortical lacunae and large vessel infarcts are assessed in more than 80% of the MC (table 1). In 35% of the cases, radiologists mention a possible etiology for their findings. In 78% of the MC, some radiologists do and others do not mention an etiology. In 6% of the cases, radiologists are present at the multidisciplinary team meeting. In 85% of the MC, physicians assess MRIs for themselves, and 81% of these assessments are used in the discussion on the diagnosis. When radiologists do not suggest an etiology, physicians more often assess MRIs for themselves (p < 0.001) and use this information in the discussion on the consensus diagnosis (p = 0.002). Discussion
In this study, we surveyed the way radiologists assess MRIs of MC patients, how they report and how multidisciplinary MC teams use these findings in their consensus discussions. The main study finding is that radiologists frequently do not report on specific signs of cerebrovascular disease. The strength of this study is the relatively high response rate, indicating that the data are representative for Dutch MC. The study results are remarkable. We found that lacunae in the deep gray matter are not reported in almost one third of the cases, and the Fazekas score is frequently not used to report on WMC. Cerebrovascular disease is common in the population over 60 years of age. WMC are prevalent in MC patients [26–28], and the severity of WMC corresponding to a Fazekas score of 2 or 3 is associated with VaD. These findings raise concern as the outcome of cerebrovascular disease can be attenuated by treating vascular risk factors. Few if any studies have examined how radiology reports are used in MC. The 2009 Dutch MC monitor reports on the number of MC, their setting and organization, the nature of diagnoses and which diagnostic tools are used. However, this is the first study to report in detail on the way MRI is used in the diagnostic process in Dutch MC. Other findings of this study are the frequent use of visual rating scales to assess MTA and GCA. Moreover, in less than half of the MC, PA and MB are radiologically assessed. PA typically signifies the presence of AD, especially in younger patients [20]. The presence of MB is considered to be a pathological phenomenon [29–32], as the presence of more than 5 MB is
284
Dement Geriatr Cogn Disord 2014;38:281–285 DOI: 10.1159/000363499
© 2014 S. Karger AG, Basel www.karger.com/dem
Boelaarts et al.: Using Magnetic Resonance Imaging in Diagnosing Dementia: A Dutch Outpatient Memory Clinics Survey
associated with a poor neuropsychological test performance [33]. Both MB and PA probably are assessed less frequent as these signs have been reported to be of use in the assessment of MRI only relatively recently. Furthermore, few radiologists report on neuroanatomical changes that may suggest the presence of FTLD or PSP. This may be explained by the lack of experience of radiologists with these entities. Consequently, this finding could mean that patients may not receive appropriate care. Finally, radiologists frequently do not report in a standardized way and do not discuss their assessment of MRIs in the multidisciplinary meeting. In the majority of the cases, physicians assess the MRIs for and use this information in discussing the consensus diagnosis. It is unknown whether the assessments of MC physicians can compensate for the underreporting of cerebrovascular disease and non-Alzheimer pathology by radiologists. A potential limitation of our study is that we asked the coordinating specialists to give a best estimation of the issues we raised in our questions. We cannot exclude that this leads to biased responses that exaggerate the main finding of this study or are an underestimation of the assessment of the typical Alzheimer pathology and large vessel disease. We thought it would not be feasible for the coordinating specialists to give quantified data where the response rate would probably be much lower. In conclusion, in Dutch MC, MTA and GCA are frequently assessed using visual scales. This may be considered a positive outcome as it reflects some standardization in radiology reports. However, VaD and non-Alzheimer pathology probably are underdiagnosed, but this may be improved by the use of a standardized protocol by radiologists to assess and report on this issues. We feel that the effect of using a standardized assessment protocol on the sensitivity and specificity of clinical diagnoses in MC outside research settings should be an issue for future study. Acknowledgment
The authors would like to thank all participants in this survey and Mrs. Luyckx for her invaluable assistance and secretarial work.
References 1
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