When the white matter lies: A case series on Binswanger’s disease masquerading as paraphrenia

Binswanger’s disease (BD), also known as subcortical arteriosclerotic leucoencephalopathy, is a rare form of vascular dementia characterized by progressive white matter demyelination and lacunar infarctions. It commonly presents with cognitive decline, psychiatric symptoms, and motor impairments. However, in some cases, the initial presentation may mimic primary psychotic disorders, delaying diagnosis. This case series describes three elderly patients who initially presented with late-onset psychotic symptoms resembling paraphrenia, such as delusions and hallucinations. However, their diagnoses were later revised to subcortical vascular dementia with behavioral and psychological symptoms, after a history of cognitive decline and executive dysfunction was identified. Each had a history of hypertension and transient ischemic attacks, suggesting an underlying vascular etiology. Neuroimaging revealed extensive periventricular and subcortical white matter changes consistent with BD. Treatment with antipsychotics led to partial improvement in psychotic symptoms, while cognitive enhancers were introduced to address cognitive deficits. Despite symptomatic relief, cognitive impairment persisted, underscoring the irreversible nature of the disease. This case series highlights the importance of considering organic causes in elderly patients with new-onset psychotic symptoms. Late-onset psychosis, especially in the presence of vascular risk factors, warrants thorough neurological evaluation. Early recognition of Binswanger’s disease allows for targeted management of vascular risk factors, such as hypertension, which may help slow disease progression and improve quality of life. Recognizing this atypical presentation can prevent misdiagnosis and inappropriate treatment, ensuring a more comprehensive approach to patient care.