Monday, 5 September 2016

Different Types of Dementia

Wessam Bou-Assaly, MD

Alzheimer’s Disease

AD is a chronic neurodegenerative disease that usually has a progressive worsening course. It is characterized by loss of neurons and synapses in the cerebral cortex,   resulting in gross atrophy of the affected regions, mainly the temporal and parietal lobes and parts of the frontal cortex and cingulate gyrus.

It is the cause of 60% to 70% of cases of dementia.

The most common early symptom is difficulty in remembering recent events ( short-memory loss). As the disease advances, symptoms can include problems in language, disorientation (including easily getting lost), mood swings, loss of motivation, not managing self care, and behavioral issues. The patients often withdraw from family and society.

Gradually, bodily functions are lost, ultimately leading to death. 

Although the speed of progression can vary, the average life expectancy following diagnosis is three to nine years.

The cause of Alzheimer's disease is poorly understood.About 70% of the risk is believed to be genetic with many genes usually involved. Other risk factors include a history of head injury, depression or hypertension.

Frontotemporal dementia ( Pick’s Disease)

Frontotemporal dementia ( also known as Pick’s disease or frontotemporal lobar degeneration) primarily affect the frontal and/or temporal lobes of the brain and are generally associated with personality and behavior.

In frontotemporal dementia, portions of these lobes atrophy. Clinical features are early personality and behavioral changes ( Disinhibition, euphoria, apathy), Compulsive behaviors (peculiar eating, habits), executive disfunction and later appearance of memory deficits. The dramatic changes in the personality is associated with socially inappropriate, impulsive or emotionally blunted behaviors.

Frontotemporal dementia is often misdiagnosed as a psychiatric problem or as Alzheimer’s disease, but it tends to occur at a younger age than does Alzheimer’s disease, typically between the ages of 40 and 70, with a more delayed occurrence of memory problems.

Dementia with Lewy Bodies

Dementia with Lewy bodies (DLB) is one of the most common types of progressive dementia. 

The central feature of DLB is progressive cognitive decline, combined with three additional defining features: 

1- Visual hallucinations.
2- Fluctuations in alertness and attention, often leading to misdiagnose as delirium.     ( frequent drowsiness, lethargy, lengthy periods of time spent staring into space, or disorganized speech; 
3- Parkinsonian motor symptoms, such as rigidity and the loss of spontaneous movement

People may also suffer from depression. The symptoms of DLB are caused by the build-up of Lewy bodies (alpha-synuclein protein) inside the nuclei of neurons in areas of the brain that control particular aspects of memory and motor control. 
The similarity of symptoms between DLB and Parkinson’s disease, and between DLB and Alzheimer’s disease, can often make it difficult for a doctor to make a definitive diagnosis. In addition, Lewy bodies are often also found in the brains of people with Parkinson’s and Alzheimer’s diseases. These findings suggest that either DLB is related to these other causes of dementia or that an individual can have both diseases at the same time. DLB usually occurs sporadically, in people with no known family history of the disease. However, rare familial cases have occasionally been reported.

Normal Pressure Hydrocephalus

Normal pressure hydrocephalus (NPH) is a form of hydrocephalus( Dilated ventricles).

It can occur without a known cause, or it may be caused by any condition that blocks the flow of cerebrospinal fluid (CSF), resulting in increased volume of CSF in the ventricles

Ataxia lack of voluntary coordination) and urinary incontinence appear early in the disease. The dementia symptoms of NPH can be similar to those of Alzheimer’s disease. 
NPH can be reversed in many people with appropriate treatment. But first it must be correctly diagnosed. NPH is thought to account for about 5% of all dementias.

Vascular Dementia

Vascular dementia is an umbrella term that describes impairments in cognitive function caused by problems in the brain blood vessels. It accounts for 15-20 % of dementia cases and the risk increases dramatically with age.

Risk factors for cerebrovascular disease include hypertension, hyperlipidemia, smoking diabetes. 

Usually there is stepwise decline in memorywith early executive dysfunction. Cerebral infarcts or white matter changes are seen on MRI.

Creutzfeldt-Jakob Disease or Prion disease

Creutzfeldt-Jakob disease (CJD) is a rare, degenerative, fatal brain disorder. It affects about one person in every one million people per year worldwide.

CJD usually appears in later life and runs a rapid course. Typically, onset of symptoms occurs about age 60, and about 90 percent of patients die within 1 year. 
The disease is characterized bbehavioral changes, rapidly progressive memory problems with myoclonus and seizures
As the illness progresses, mental deterioration becomes pronounced and involuntary movements, blindness, weakness of extremities, and coma may occur.

Wernicke-Korsakoff Syndrome

Wernicke-Korsakoff syndrome is caused by a thiamine ( Vitamin B1) deficiency. 
It involves damage to multiple nerves in both the central nervous system (brain and spinal cord) and the peripheral nervous system.

The cause is generally attributed to malnutrition, especially lack of vitamin B1 (thiamin), which is common in those with alcoholism. Heavy alcohol use interferes with the breakdown of thiamin in the body, so even if someone with alcoholism follows a well-balanced diet, most of the thiamin is not absorbed.

Wessam Bou-Assaly, MD is a Neuroradiologist with long years of experience.

Saturday, 3 September 2016


    Wessam Bou-Assaly, MD

Alzheimer disease (AD) is a progressive neurodegenerative disorder characterized by the gradual onset of demetia. The pathologic hallmarks of the disease are beta-amyloid  plaques, neurofibrillary tangles (NFTs), and reactive gliosis.

Alzheimer disease was first described in 1907 by Alois Alzheimer and has become one of the most common diseases in the aging population, ranking as the fourth most common cause of death. 

It is the most common cause of dementia, responsible for 60-80% of all dementias. 

The prevalence is strongly linked to age, with >1% of 60-64 year old patients being diagnosed with the condition, compared to 20-40% of those over 85-90 years of age.

Epidemiological risk factors include:

-Advanced age 
-Female gender 
- Apolipoprotein E (APOE) ε4 allele carrier status
-Current smoking 
-Family history of dementia 
-Mutations of amyloid precursor protein


Clinical diagnosis is made by identifying progressive decline in memory both with clinical examinations and neuropsychologic tests and has been historically based on the the INCDS-ADRA criteria, which divides patients according to the certainty of the diagnosis into 5

1. Definite: clinical diagnosis and histologic confirmation.

2. Probable: typical clinical syndrome without histologic confirmation 81% sensitive, 73% specific.

      3. Possible: atypical clinical features without histologic confirmation. 



The initial criteria for CT scan diagnosis of Alzheimer disease includes diffuse cerebral atrophy with enlargement of the cortical sulci and increased size of the ventricles.

Disproportionate atrophy of the medial temporal lobe, particularly of the volume of the hippocampal formations (< 50%), is highly suggestive of AD.

Dilatation of the perihippocampal fissure is a useful radiologic marker for the initial diagnosis of Alzheimer disease, with a predictive accuracy of 91%. The hippocampal fissure is surrounded laterally by the hippocampus, superiorly by the dentate gyrus, and inferiorly by the subiculum. These structures are all involved in the early development of Alzheimer disease and explain the enlargement in the early stages. 


Magnetic resonance imaging (MRI) is considered the neuroimaging of choice for Alzheimer disease because it allows for accurate measurement of the 3-dimensional (3D) volume of brain structures, especially the size of the hippocampus and related regions.

MRI is also useful for excluding reversible causes of dementia syndrome, such as normal pressure pressure hydrocephalus, brain tumors, and subdural hematoma, and for excluding other likely causes of dementia, such as cerebrovascular disease.

The primary role of MRI in the diagnosis of Alzheimer disease is the assessment of volume change in characteristic locations which can yield a diagnostic accuracy of up to 87% . 

The diagnosis should be made on the basis of two features:

1. Mesial temporal lobe atrophy.

2. Temporoparietal cortical atrophy.

Mesial temporal lobe atrophy can be viewed directly by assessing for hippocampal and parahippocampal decrease in volume, or indirectly by examining enlargement of the parahippocampal fissures. 

The former is more sensitive and specific but ideally requires actual volumetric 
calculations rather than simple visual assessment. These measures have been combined in 
the “medial temporal atrophy score  which has been shown to be predictive of 
progression from mild cognitive impairment (MCI) to dementia.

Particularly relevant to early onset Alzheimer disease, is the presence of temporoparietal and parietal atrophy. This is often best seen on the interhemispheric surface of the parietal lobe by examining the posterior cingulate sulcal and
parietoccipital sulcal size and degree of atrophy of the precuneus and cortical surface of the parietal lobe. This has also been combined into a scoring system.

18-FDG Positron Emission Tomography (PET)

F-18 FDG PET typically shows bilateral temporoparietal, precuneus and posterior cingulate hypometabolism which is usually symmetric. Uptake may be asymmetric in the early stages.

Amyloid PET

Pittsburgh Compound Balong with newer compounds such as florbetapir, flutametamol, and florbetaben, are molecules that bind preferentially to beta-amyloid fibrils is being used with PET and may be able to improve the specificity of AD diagnosis, although there is considerable overlap with normal controls. 

With increased cerebral amyloid-β (Aβ) deposition, increased activity is demonstrated in the cortex. It is particularly useful in excluding Alzheimer's disease as the cause of dementia, since a negative amyloid PET scan makes the diagnosis unlikely.

Wessam Bou-Assaly, MD is a Radiologist specialized in Neuroradiology and Head and Neck Imaging. 

Monday, 8 August 2016

Wessam Bou-Assaly - How To Create Poetry

Wessam Bou-Assaly loves to read poetry, and enjoys talking about the subject whenever he can find someone who is equally enthusiastic about poems. Many people don’t realize that writing verses can be a liberating experience, even if someone is not especially talented.

Finding Inspiration
Finding inspiration is crucial. We can call it a muse, or anything else, but it doesn’t have to be a person. It can be a place, or even an activity, something that evokes inspiration. Once it’s there, all you have to do is feed it.

Capture a Moment
Many enthusiasts make the mistake of trying to hit the ball out of the park, trying to write a very long poem with an intricate story. A moment can often be much more powerful, conveying all the emotions that you try to summon in a brief, spontaneous poem.

Create (or Steal) a Conversation
Talking to others is a big part of the human experience, one that most people could not live without. This is probably also the reason why we so often find these conversations fascinating and inspiring. Every interaction holds some potential when it comes to writing poetry. Listening to others can have a similar effect, so walk around with open ears.

Write Often
Writing poems will require just that, writing. There are many prominent writers out there who don’t believe in the phenomenon called writer’s block. Just starting the process – even if it doesn’t result into a poetical masterpiece – can make a difference.

Wessam Bou-Assaly loves to read poems and hopes that they will make a comeback in many people’s lives.


Thursday, 28 July 2016

Wessam Bou-Assaly - The Medical Benefits of Playing Tennis

As a physician who happens to like tennis a lot, Wessam Bou-Assaly has a very clear idea about the potential physiological benefits of playing the sport.

Sport Science Stats

The USTA (United States Tennis Association) funded some very interesting studies, one of which found a very clear link between the frequent practice of the sport and a reduced chance for sudden cardiac arrest. Those who play tennis at least 3 hours a week at moderate to high intensity, could reduce their risk of suffering sudden cardiac arrest by as much as 50%.

A Potentially Brain Stimulating Exercise

Tennis is an intense game that requires participants to stay alert at all times, as well as to think tactically. This could lead to new nerve connections in the brain, which is otherwise a well-documented phenomenon

Being Competitive Burns More Calories 

Playing competitive tennis (which doesn’t equal professional tennis) burns more calories than a lot of other exercises praised for their ability to work the body. These exercises include but are not limited to: aerobics, skating and even cycling.

Tennis Players Tested

Dr. Joan Finn did a study at the Southern Connecticut State University, testing various subjects and comparing their mental state based on different criteria. According to the results, tennis players – on average – were more optimistic and had a higher self-esteem than those who did not play the sport.
Wessam Bou-Assaly is a radiology expert who loves to exercise whenever he has the time, with tennis being one of his favorite sports.


Thursday, 21 July 2016

Wessam Bou-Assaly on “The Championships”

As an avid tennis fan who loves to follow the game as much as he likes to play it, Wessam Bou-Assaly appreciates the special sporting event that the Wimbledon Grand Slam is every year. When asked to pick the best, most prestigious one out of the four Grand Slams, most people usually mention Wimbledon, and they probably have very good – and valid – reasons to do that.


For starters, Wimbledon is the oldest out of the four, having been founded in 1877, four years before the US Open. While its age is important, that’s not the only reason for this distinction. The other – and probably more important – is its status. Until the 1924/1925 season, Wimbledon was the only Grand Slam tournament. It was only that year when the other three tournaments (Australian Open, French Open, and US Open) have joined Wimbledon in the rankings, starting a new era in tennis.

Played on Grass

There is just something majestic about grass. Maybe it’s the fact that grass courts are – by far – the rarest out of all surfaces. There are not a whole lot of grass courts around the world, certainly not if we go by professional standards.

The Location

The fact that it is played in London, often in the courtesy of one or more members of the royal family, doesn’t hurt its case either. Even the Queen has attended the tournament in recent years, several decades after her previous visit which took place in 1977. As a big fan of the game, Wessam Bou-Assaly appreciates the role that Wimbledon plays in the tennis world.


Sunday, 17 July 2016

Wessam Bou-Assaly: Disc Disease and Radiology



Disc Disease and Radiology

          Wessam Bou-Assaly, MD


The intervertebral discs are spongy cushions elements, formed by strong connective tissues that separate the vertebral bodies of the spine. These have many important functions including shock absorption, stability of the vertebral column and giving the vertebrae pivot points for its movement.


A disc is made of two parts: the annulus fibrosis, an elastic outer shell and nucleus pulposus, a jelly-like central content.

With age and with certain types of pressure the annulus fibrosis can be damaged and the nucleus bulge through it.

Risk Factors:


Some people are more susceptible to disc problems than others. Risk factors include:
-Poor muscle tone
-Lack of exercise.
-Cigarette smoking
-Advancing age
-Poor posture
-Incorrect lifting techniques.

But often, there is no recognizable risk factor present.



The symptoms of disc problems vary according to its location, its severity and its compression on the adjacent structure, mainly the spinal cord or nerve roots. Many people with disc herniation on MRI have no symptoms.


Symptomatologic disc problem complains may include:


-Back pain with or without radiation down the legs.

-Worsening pain associated with bending over or sitting down for a long time.

-Pain associated with activities like coughing or sneezing.

-Numbness or pins-and-needles in an arm or leg.


-Loss of bladder or bowel control.



Diagnosis is of course suspected during taking medical history and when performing physical examination.


Radiology plays crucial role in diagnosing disc problem. The X-ray, even though limited in visualizing and evaluating the intervertebral disc, can shows signs of degenerative changes in the spine, which can be associated with underlying disc disease.


Signs of degenerative changes on X-Ray includes disc space narrowing, endplates sclerosis and presence of osteophytes.

MRI is the modality of choice in diagnosis disc degeneration and its effect on adjacent structure such as spinal cord and nerve roots.

MRI can precisely evaluate the type of herniated is material.


1- Diffuse disc bulge: Herniated disc tissue "circumferentially" (50–100%) beyond the edges of the vertebra. It is not considered a form of herniation.


It could be Symmetrical:

Or Asymmetrical:

2- Broad based disc herniation: Herniation between 25% and 50% (90 –180°) of the disc circumference.

3- Focal herniation: Involves less than 25% or 90° of the disc circumference.

Focal disc herniation versus Broad base:

Focal disc herniation can also be classified as protrusion or extrusion, based on the

shape of the displaced material.


Protrusion is present if the greatest distance, in any plane, between the edges of the herniated disc material beyond the disc space is less than the distance between the edges of the base, in the same plane.


Extrusion is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base, or when no continuity exists between the disc material beyond the disc space and that within the disc space.

A sequestration is present when there is discontinuity between the herniated disc material and the parent disc

Wessam Bou-Assaly, MD is a Neuroradiologist. He has many years in experience in medical Imaging fields.