MRI findings are often missed in the diagnosis of Creutzfeldt-Jakob disease.

Christopher Carswell,Andrew Thompson,John Stevens,Simon Mead,Ana Lukic,John Collinge,Harpreet Hyare,Peter Rudge

doi:10.1186/1471-2377-12-153

Christopher Carswell, Andrew Thompson + Show 6 more

Open Access

https://doi.org/10.1186/1471-2377-12-153

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Abstract

BackgroundEstablishing a confident clinical diagnosis before an advanced stage of illness can be difficult in Creutzfeldt-Jakob disease (CJD) but unlike common causes of dementia, prion diseases can often be diagnosed by identifying characteristic MRI signal changes. However, it is not known how often CJD-associated MRI changes are identified at the initial imaging report, whether the most sensitive sequences are used, and what impact MRI-diagnosis has on prompt referral to clinical trial-like studies.MethodsWe reviewed the MRI scans of 103 patients with CJD referred to the National Prion Clinic since 2007 and reviewed the presence of CJD-associated changes, compared these findings with the formal report from the referring centre and reviewed the types of sequence performed.ResultsIn sCJD we found CJD-associated MRI changes in 83 of 91 cases (91% sensitivity). However, the referring centres documented CJD-associated MRI changes in 43 of the sCJD cases (47% sensitivity). The most common region not documented by referring centres was the cortex (23 of 68 sCJD cases), but there was a statistically significant discrepancy in all regions (p<0.0001). Patients in whom MRI abnormalities were missed by the referring hospital were more advanced at the time of recruitment to a clinical trial-like study (p=0.03).ConclusionsCJD-associated MRI changes are often not documented on the formal investigation report at the referring centre. This is important as delay makes enrolment to clinical trials futile because of highly advanced disease. If a diagnosis of CJD is suspected, even if the initial imaging is reported as normal, a specialist MRI review either by an experienced neuroradiologist or by a prion disease specialist unit could facilitate earlier diagnosis.

Highlights

Establishing a confident clinical diagnosis before an advanced stage of illness can be difficult in Creutzfeldt-Jakob disease (CJD) but unlike common causes of dementia, prion diseases can often be diagnosed by identifying characteristic MRI signal changes
We obtained 133 MRI scans from 113 patients referred to the National Prion Clinic (NPC) between 01.03.2007 and 24.05.2010 with a suspected diagnosis of CJD. 30 scans were excluded: 21 cases did not fulfil the WHO diagnostic criteria for CJD or were thought clinically to be due to a different cause; the referring report could not be obtained in 9 cases
In sCJD, we found characteristic increases in MRI signal intensity in 83 of the 91 cases at NPC review, a sensitivity of 91% for MRI in the diagnosis of CJD in this series (Table 1)

Summary

Introduction

Establishing a confident clinical diagnosis before an advanced stage of illness can be difficult in Creutzfeldt-Jakob disease (CJD) but unlike common causes of dementia, prion diseases can often be diagnosed by identifying characteristic MRI signal changes. It is not known how often CJD-associated MRI changes are identified at the initial imaging report, whether the most sensitive sequences are used, and what impact MRI-diagnosis has on prompt referral to clinical trial-like studies. More recently MRI criteria have been added giving a sensitivity and specificity >90% for suitable for the study of whom 70% had an autopsy or cerebral biopsy

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