Severe depressive pseudodementia with and without dementia

Recent work has documented the existence of the syndrome of pseudodementia. The authors present four cases of depressive pseudodementia, two without associated dementing illnesses and two that occurred in the context of dementing illnesses. These cases emphasize the difficult nature of differential diagnosis and the profound cognitive impairment that can occur in depressive illness. They also document the coexistence of pseudodementia with "true" dementia. The authors discuss diagnostic and management issues for clinicians treating patients with pseudodementia and depressive illness.

Brain stem and cerebellar dysfunction with Legionnaires' disease

A 37-year-old man under treatment for manic-depressive illness developed pneumonia identified as Legionnaires' disease accompanied by a severe neurological disorder with profound dysarthria, ataxia, gaze paralysis, and downbeat nystagmus. At review six months later, he has made only a partial recovery with persisting limb and gait ataxia. Difficulties in diagnosing neurological complications of Legionnaires' disease in a patient with a psychiatric disorder requiring psychotropic medication are discussed.

Angioimmunoblastic lymphadenopathy. Its occurrence with meningeal involvement

A case of angioimmunoblastic lymphadenopathy with involvement of the leptomeninges and the lumbosacral nerve roots was studied. This condition seems related to malignant lymphoma, and clinical improvement occurred with administration of systemic corticosteroids.

The dose-response ratio in electroconvulsive therapy a preliminary study

To investigate pretreatment patient variables that might correlate with dose-response characteristics of electroconvulsive therapy (ECT) and treatment outcomes, 14 patients were assessed on a daily basis, before and during treatment, using self-report affective scales, three simple paper-and-pencil tests of cognitive function,and finger-tapping speed. From these data, dose-response ratios and treatment outcome measures were derived. The dose-response ratio of ECT was found to correlate with age--the younger the patient, the more favorable the ratio. This finding is discussed in terms of the known relationships between brain monoamine oxidase levels and age, and the established relationship between seizure duration and treatment efficacy. The dose-response ratio over the first two electroconvulsive treatments as well as lesser degrees of initial congnitive and greater degrees of initial affective impairment correlated strongly with greater overall affective improvement. Some clinical and research implications of these findings are discussed.

Cooperative study of hospital frequency and character of transient ischemic attacks. VIII. Risk factors

A total of 969 (73%) of 1,328 patients with cases of suspected transient ischemic attacks (TIAs) who came to six institutions during a 21-month period were followed up. Factors were identified and prospectively analyzed for risk for further TIAs, stroke, and deatn. A history of multiple carotid artery TIAs was significantly related to further TIAs. A single TIA placed the patient at greater risk for early infarction. Older age, male sex, and unreliability to take dangerous medication were risk factors for cerebral infarction. Anticoagulant therapy, older age, male sex, diabetes mellitus, heart disease, abnormal ECG, and poor surgical risk were factors for death. The increased mortality associated with anticoagulants was confined to the older age group. While white patients treated with antiplatelet-aggregating agents had a lower mortality than those treated otherwise, this was not true amont black patients.

Cooperative study of hospital frequency and character of transient ischemic attacks

Information was collected among six participating medial centers on frequency of performance and the percentage of abnormality of 30 tests performed on patients with complaints suggesting transient ischemic attacks (TIAs). A number of these were commonly performed and commonly exhibited abnormalities. Although the diagnosis of TIA is made by history and physical examination, these tests were of value in aiding the physician to determine possible causes of TIA, to detect risk factors of associated conditions, to rule out alternative diagnoses, and to assess the patient's ability to tolerate different types of therapy.

Cooperative study of hospital frequency and character of transient ischemic attacks. VI. Patients examined during an attack

Examination during an episode of transient ischemic attack (TIA) was performed on 121 of 1,307 patients suspected of having a single type of TIA. This examination supported the diagnosis of TIA in 79 patients and contributed to the establishment of a diagnosis other than TIA in 42. Although the examination increased diagnostic reliability, it did not always result in a definite diagnosis. The most common neurologic findings during a TIA were weakness of an arm or side of the face. Important findings not suggested by history included visual defects and blood pressure fluctuation. Also unexpected were the absence of findings such as sensory deficits in the presence of sensory complaints, retinal emboli, and cardiac abnormalities. Severe arteriosclerotic disease was less evident, the attacks were longer and more severe, and monocular blindness was rare.

Cooperative study of hospital frequency and character of transient ischemic attacks. V. Symptom analysis

All patients (1,328) suspected of having transient ischemic attacks (TIA) who came to six institutions during a 21-month period were identified. Symptoms and symptom complexes were related to the clinical diagnoses by cross-tabulation, factor analysis, and discriminant analysis. The diagnoses obtained by the discriminant analysis program were comparable to those of reviewing clinical neurologists. Symptoms of importance in the vertebral-basilar system (VBS) were bilateral visual blurring, diplopia, ataxia, and dizziness; In either carotid system (CAS), ipsilateral monocular visual disturbance anc contralateral weakness or sensory complaints; in the left CAS, language disturbances; and in those whose ultimate diagnosis was not TIA, loss of consciousness, confusion, and bilateral leg weakness. Patients with VBS TIAs have symptoms common to conditions that are not TIA and have a greater variety of symptoms and more combinations of symptoms than CAS TIA.

Cooperative study of hospital frequency and character of transient ischemic attacks. IV. The reliability of diagnosis

All patients (1,328) suspected of having transient ischemic attacks (TIA) who came to six institutions over a 21-months period were identified. Each case was reviewed by a neurological investigator, and a definite diagnosis of TIA was supported in 39% and ruled out in 30%. The reliability of the neurologist's review diagnosis was assessed by three methods, and close agreement (84% to 93%) was obtained. Factors demonstrated to effect the diagnosis were historical information, neurological training of the examiners, type of symptom complex, presence of carotid artery bruits, and examination during an attack.

Cooperative study of hospital frequency and character of transient ischemic attacks. III. Variations in treatment

Variations in therapy for patients with complaints suggesting transient ischemic attacks (TIAs) among six participating medical centers are described. Selected treatment, based on clinical interpretation of patient characteristics, varied widely among centers. Therefore, results cannot be attributed to specific treatment. Nevertheless, there was little difference between treatment categories and the likelihood of further TIAs. The mortality of the patients who had received anticoagulants was significantly higher (P less than .001) than those patients receiving other treatment. Possible reasons for these differences are discussed.

A cooperative study of hospital frequency and character of transient ischemic attacks. II. Performance of angiography among six centers

Angiographic procedures were carried out on 36% of 1,328 patients suspected of having transient ischemic attacks (TIA). Among six participating centers, this ranged from 13% to 82%. This large difference might be related to the number of patients considered good surgical candidates and differences in the use of screening noninvasive diagnostic techniques. Arch studies, using catheter techniques, were performed most often. Although 13% of the patients had transient complications, permanent neurological deficits occurred in only 0.65%. Angiographic lesions were best correlated to clinical symptoms in those patients thought to definitely have carotid artery system TIA but were commonly seen in all other groups. Thus, clinical correlation was poor.

Cooperative study of hospital frequency and character of transient ischemic attacks. I. Background, organization, and clinical survey

To better understand transient ischemic attacks (TIA), all patients (1,328) with TIA-like symptoms were identified at six participating institutions representing known variations in geography, referral patterns, and socioeconomic status. A total of 954 patients were observed for a mean of 14.3 months. Problems in diagnosis are defined, demographic information is summarized, and features of the histroy, examination, tests, and treatments are noted.

Psychiatric and behavioral manifestations of normal pressure hydrocephalus. A case report and brief review

Normal pressure hydrocephalus (NPH) may suggest its presence by behavioral symptoms. Initally, the symptoms often manifest themselves as depression with marked psychomotor retardation. Older patients without a prior psychiatric history who have soft, nonlocalizing neurological signs and fluctuating cognitive and memory deficits in association with prominent affective and/or psychotic symptomatology of recent onset, such as the case reported here, should raise the clinician's index of suspicion. In such cases, the Halstead-Reitan neuropsychological battery may be helpful in differentiating an underlying dementia from a primary psychological dysfunction. When the presence of a dementing process is suspected, etiological diagnosis should be vigorously pursued with a CAT scan and, as indicated on clinical grounds, confirmatory and further delimiting studies such as pneumoencephalography, ventriculography, RISA scanning, electroencephalography, constant-infusion manometric testing, and/or angiography. Treatment of NPH includes one of several forms of shunting procedures and appropriate neuroleptic therapy for behavioral symptoms. Althoug there is a substantial risk (40 to 50 percent)ioral symptoms. Although there is a substantial risk (40 to 50 per cent) of shunt-related complications, as many as 60 per cent of operated patients will show objective imprvement, making the diagnosis of and referral for appropriate surgical treatment of NPH an important challenge for the psychiatrist.

Disulfiram-induced convulsions without challenge by alcohol

A patient who had several grand-mal seizures while taking disulfiram in the absence of a challenge with alcohol is described and some of the possible mechanisms for this occurrence are discussed.

Opacity pulse propagation measurement and thermometry in the evaluation of carotid occlusive vascular disease: correlations with angiography

A correlative study of four-vessel angiography with measurements of opacity pulse propagation times and skin temperatures over the medial supraorbital areas of the forehead was carried out in 46 patients. Differences in propagation times of greater than 12 milliseconds and/or in thermometric measurements of 1 °F or more were always associated with angiographically demonstrable carotid occlusive disease. In patients with positive angiographical findings, prolongation of pulse propagation time was associated with lower skin temperature when the latter occurred. Test results indicated abnormality in six of seven patients with bilateral carotid occlusive disease. By these methods, unilateral occlusive lesions of 30% to 50% of the vascular lumen were detected in three of five instances where such lesions occurred; occlusive lesions greater than this degree were detected in 15 of 18 patients. The tests identified as "normal" 18 of 23 patients whose four-vessel angiograms were either totally unremarkable or showed lesions compromising less than 30% of the carotid lumen. Combination of these screening tests is more useful than either test employed alone and may be helpful in clinical evaluation of patients with cerebrovascular disease.

Opacity pulse propagation measurements in humans: atraumatic screening for carotid arterial occlusion

Opacity pulse propagation times to areas of facial skin supplied by internal carotid (medial supraorbital area) and external carotid arteries (lateral supraorbital areas, cheeks, etc.) were carried out in 27 patients with cerebrovascular symptoms, 16 of whom had normal four-vessel angiographical studies and 11 of whom had unilateral carotid occlusion. In most persons with normal extracranial vessels, no significant difference is found between mean values of propagation time to internal carotid beds on the two sides of the face or between homologous areas of the face supplied by external carotid branches. With unilateral internal carotid occlusion, mean propagation time is prolonged to the medial supraorbital (internal carotid) area on the side of occlusion, while mean propagation times to external carotid beds do not differ significantly. Occlusion of the common carotid artery results in prolongation of mean propagation time to both internal and external carotid beds on the side of the arterial obstruction. Limitations of the technique and possible sources of error are discussed. The preliminary results reported suggest that this technique may be useful in atraumatic evaluation of patients for carotid arterial disease.