Before this study, the written informed consent was obtained from the patient, and the study was approved by the regional ethics committee of The First Affiliated Hospital of Yangtez University Medical School, and performed in accordance with the Declaration of Helsinki. The patient is a 58-year-old Chinese male who was mentally able to work as a policeman 1 year ago. He was normal nutritional and has no drug addiction habits as well as psychiatric disorders before. Six months ago, he began to suffer mild insomnia and episodes of recent memory loss, then sought medical treatment in our hospital.
His pulse was 78 beats/min and regular, and blood pressure was 130/65 mm Hg. The consciousness was sensitive and Glasgow Coma Scale sore was 15. Cranial nerves examination was negative. For motor function, the patient had normal muscle strength (grade 5) and normal muscle tone (grade 0). According to Kendall report, the grading scale of muscle strength ranges from 0 to 5. Briefly, grade 0, no visible or palpable contraction; grade 1, visible or palpable contraction with no motion; grade 2, full range of motion (ROM) gravity eliminated; grade 3, full ROM against gravity; grade 4, full ROM against gravity, moderate resistance; grade 5, normal, full ROM against gravity, maximum resistance. In terms of muscle tone, based on the Ashworth classification, muscular tone was divided into 5 grades from normal (grade 0) to limited flexion and extension (grade 4). Stance and gait was freely without involuntary movements. Finger-to-nose test, heel-knee-shin test and Romberg sign test were all negative. Sensory examination was normal. Finally, reflexes check shows symmetrical and pathologic reflexes were negative.
Laboratory examinations of routine blood, homocysteine, VitB12 and folic acid were normal. For the first time, MRI scans were not performed due to the patient's implanted metal dentures. In order to get his MRI image, with the consent of the patient, his implanted dentures were removed before MRI scans so as to avoid inhalation of the respiratory tract and other potential hazards. His mini-mental state examination (MMSE) score was 27 (see Table 1). These results were almost normal and acceptable in this aged people.
Montreal Cognitive Assessment (MoCA) screening for MCI is more sensitive than MMSE (Nasreddine et al.,). Then we conducted MCI exam with a serial scale for this patient. The results showed that his MoCA examination score was 25 out of 30 with mainly deficits in visuospatial/executive (4/5), delayed recall (3/5) and orientation (4/6; see Table 2). In addition, we tested Activity of Daily Living Scale (ADL) for daily life functioning, and Hamilton Anxiety and Depression Scale (HAMA, HAMD) for mental state. These results showed that memory impairments were not relevant in daily life and state of mind during his work in a police office. Therefore, we gave a diagnosis of MCI at that time according to National Institute of Neurological Disorders and Stroke-Alzheimer's Disease and Related Disorders (NINCDS-ADRDA) Criteria 2011 (Guo et al.,).
Then, the patient was treated with alprazolam and donepezil but did not return regularly for follow-up visits. Six months after his first visit, he began to have severe sleepless and misidentification with movie characters and his family members. In addition, he could not perform simple calculations or shopping alone, even routine daily-work. His cerebrospinal fluid was collected, the pressures was 155 mm H2O. Bacterial and virus battery, 14-3-3, total tau, phosphorylated tau181 and Abeta42 were analyzed. All the above measurements showed negative results.
The patient's MMSE score was 18 (see Table 1), therefore we gave a diagnosis of probable Alzheimer's disease according to NINCDS-ADRDA Criteria 2011. Moreover, compared with the matched control whose brain shows mild atrophy without SPC, and his cognitive functions are normal (Figures 1A,B). The MRI results showed that the double lateral ventricles were significantly expanded (Figure 1C) and the space-occupying lesions in the midline area were clearly observed (Figure 1D). In consideration of the above tests, the final diagnosis for this patient was suspected dementia induced by SPC. Then, he was transferred to the department of neurosurgery for minimally invasive surgical treatment. Neuroendoscopic fenestration of the SPC was successfully performed via a right frontal approach using a high-resolution flexible neuroendoscopic system without complication. Communication between the cyst cavity and bilateral ventricles was constructed via a single trajectory. Two months after treatment, the patient returned us a visit. We rechecked him by MRI and MMSE. The MRI results confirmed a shrinkage of the expanded lateral ventricles (Figure 1E) and elimination of SPC (Figure 1F). Meanwhile, his MMSE score was 28 (see Table 1), and he was able to be competent at both his job and daily life. In the later 2 months of brief follow-up period, the patient showed better adherence and tolerability and no adverse events could be observed.