Discussion

A diagnosis of Binswanger’s disease was proposed for our patient based on the clinical features regarding the risk factors, general and neurological examination, the white matter changes observed on CT and MRI and also a thorough differential diagnosis. More than 20 years have passed since Benett and Caplan proposed a diagnostic criterion for Binswanger’s disease 2. The pathophysiology of the disease has been better understood since then and besides the usual clinical features and imaging, ancillary tests can be used in difficult cases 5. Changes in CSF biochemistry may reflect the neuro-inflammation present in small vessel disease. Neuro-inflammation leads to blood-brain barrier dysfunction with increased permeability on the one hand and important changes in the protein and cytokine expression patterns in glial cells on the other hand. These changes may be reflected by an increased albumin index in the CSF (due to increased permeability) and in increased levels of inducible matrix metalloproteinases, such as MMP-3 and MMP-9 (due modified protein expression) 5,6,22. A recent biomarker identified as having larger levels is patients with Binswanger’s disease is lipocalin 2 (LCN2). LCN2, also known as oncogene 24p3, a glycoprotein involved in NVU damage in patients with vascular disease. It had promising results and was found having larger levels in patients with vascular dementia as opposed to Alzheimer’s disease or other types of dementia 24.
Various imaging studies such as MRI diffusion tensor imaging (to evaluate white matter tracts integrity) or dynamic contrast enhancement MRI (to reveal disruption of the blood-brain barrier) can aid the clinician in establishing the diagnosis. These imaging techniques and many others have unknown reproducibility and lack validation for Binswanger’s disease in larger populations. It is important to mention that the diagnosis cannot be given solely on CT or MRI imaging and requires a careful clinical examination. 5,22, 23
Establishing the diagnosis for Binswanger’s disease requires a multimodal approach. None of the biomarkers alone are adequate to diagnose the disease, but using clinical data alongside imaging and ancillary tests can prove helpful in patients with cognitive impairment and neurological signs with uncertain or unknown etiology5,6,22,23.