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.