Clinical features and treatment response of patients with major depression and silent cerebral infarction

Previously, we reported a relationship between silent cerebral infarction (SCI), as detected by magnetic resonance imaging (MRI), and late onset major depression. In the present study, we clarify the clinical features of the depressive phase of patients with major depression and SCI, and their response to antidepressant pharmacotherapy. Using clinical charts, we retrospectively examined patients with depression, who were first admitted for antidepressant pharmacotherapy. All patients were classified according to the MRI findings and the age on admission (older or younger than 50 years) into either the young SCI(-) group (n = 23), the elderly SCI(-) group (n = 27) or the elderly SCI(+) group (n = 20).The characteristics of the clinical features were evaluated at the time of admission, after 2 weeks of treatment and at the time of discharge using the Hamilton rating scale for depression (HAMD). These data were compared between each patient group. No differences in the clinical features, as evaluated by HAMD, were observed between the three groups at the time of admission. However, the mean length of treatment was significantly longer and the treatment response, as evaluated by the total HAMD score, was significantly worse in the elderly SCI(+) group than in the other two groups, when examined after 2 weeks of treatment and at the time of discharge. The elderly SCI(+) group demonstrated higher scores in feelings of guilt, suicide, retardation and hypochondriasis than the young SCI(-) group and the elderly SCI(-) group after two weeks of treatment, and higher scores in early insomnia, late insomnia, somatic anxiety and hypochondriasis at the time of discharge. Our findings suggest that while the presence of SCI does not affect the clinical features observed at the time of admission, it does affect the treatment response to antidepressant pharmacotherapy.

Neuropsychological aspects of pediatric sickle cell disease

Sickle cell disease (SCD), a class of genetic disorders characterized by abnormal, sickled red blood cells, is a chronic illness that results in progressive cerebrovascular disease. Neurocognitive sequelae of clinically apparent cerebrovascular accidents in children with SCD are characterized by pervasive impairments, including decrements in general intellectual functioning, language and verbal abilities, visual-motor and visual-spatial processing, memory, academic achievement, and processing of subtle prosodic information. In contrast, subtle neurocognitive deficits in the areas of attention and concentration, executive function, and visual-motor speed and coordination appear to be associated with silent infarcts that are not necessarily detected on physical examination. Investigation of the disease course and associated neurocognitive sequelae suggest a disease-specific model of neuropsychological impairment. Recommendations are made for clinical and research efforts in the field of pediatric neuropsychology.

Catastrophic reaction in acute stroke: a reflex behavior in aphasic patients

Twelve patients with a catastrophic reaction (CR) (an outburst of frustration, depression, and anger when confronted with a task) were identified in a prospective cohort population (n = 326) with first-ever stroke admitted within 48 hours from onset. The authors' findings suggest that CR is a rare though not exceptional phenomenon in acute stroke and is associated with nonfluent aphasias and left opercular lesions. CR, poststroke depression, and emotionalism are distinct but related disorders.

Assessment of calculation and number processing using the EC301 battery: cross-cultural normative data and application to left- and right-brain damaged patients

To provide referential normative data on simple tasks dealing with number processing and calculation which could be used in clinical investigations, 551 normal volunteers aged between 18 and 69 years from France and Belgium (n = 180). Italy (n = 212) and Germany (n = 159). performed the 31 tasks which constitute the EC301 calculation and number processing battery. Differences between countries were significant for 16 tasks and a Gender x Education interaction was observed for some tasks, with men performing better than women among subjects with low education only. To present an overview of preserved and impaired calculation and number processing abilities in left-brain damaged (LBD) aphasic patients and right-brain damaged (RBD) nonaphasic patients, the 31 subtests of the EC301 battery were proposed to 80 patients with cerebrovascular accident, 56 left and 24 right, for most cases in the territory of the middle cerebral artery. LBD aphasic patients showed low performance on oral and alphabetical spoken verbal and written verbal counting, transcoding when a written code was involved, and mental or written calculation; but relatively good performance at finding the number of elements in small sets, comparing numbers written in the Arabic digital code and placing correctly numbers on an analogue number line. The lowest performances of RBD patients were observed for estimation tasks and for placing a number on a scale. Results and their implications for further research are discussed according to the present information processing and anatomofunctional models of calculation and number processing.

Hemispheric perception of emotional valence from facial expressions

The authors previously reported that normal subjects are better at discriminating happy from neutral faces when the happy face is located to the viewer's right of the neutral face; conversely, discrimination of sad from neutral faces is better when the sad face is shown to the left, supporting a role for the left hemisphere in processing positive valence and for the right hemisphere in processing negative valence. Here, the authors extend this same task to subjects with unilateral cerebral damage (31 right, 28 left). Subjects with right damage performed worse when discriminating sad faces shown on the left, consistent with the prior findings. However, subjects with either left or right damage actually performed superior to normal controls when discriminating happy faces shown on the left. The authors suggest that perception of negative valence relies preferentially on the right hemisphere, whereas perception of positive valence relies on both left and right hemispheres.

The role of perceptual load in neglect: rejection of ipsilesional distractors is facilitated with higher central load

Neglect is known to produce a bias towards the ipsilesional side. Here we examined whether this bias is automatic or can be modulated by manipulating perceptual load in a relevant task [e.g., Lavie, N. (1995). Perceptual load as a necessary condition for selective attention. Journal of Experimental Psychology: Human Perception and Performance, 21, 451-468]. Three patients with left neglect and three healthy controls made speeded choice responses to a target letter in the center of the display while attempting to ignore an irrelevant distractor presented on left or right. Perceptual load was manipulated by inducing a search for the target that appeared with another central stimulus, which was either a blob (low load) or a nontarget letter (higher load). Response competition effects from ipsilesional distractors were significantly reduced by higher load. The same increase of load, however, did not decrease distractor effects in the control group, as expected [e.g., Lavie, N., & Cox, S. (1997). On the efficiency of attentional selection: Efficient visual search results in inefficient rejection of distraction. Psychological Science, 8, 395-398]. These results demonstrate that ipsilesional bias in neglect is not fully automated and emphasize an additional restriction of perceptual capacity. Moreover, they supported our prediction that reduced perceptual capacity in neglect can lead to improved distractor rejection with just small increases in perceptual load.

Abulia and cognitive impairment in two patients with capsular genu infarct

BACKGROUND

An internal capsule genu infarct has been rarely reported to cause cognitive impairment and behavioral changes. This clinical picture can be explained on anatomical and functional basis because important subcortical-cortical pathways traverse the internal capsule genu. We report 2 previously non-demented patients who developed acute confusional state, abulia, and moderate cognitive decline after the occurrence of an infarct in the capsular genu.

METHODS

Clinical, neuropsychological, and MRI evaluation at baseline and 12-month follow-up.

RESULTS

Abulia and cognitive impairment were still present 1 year after stroke. In 1 patient there were associated multiple lacunar infarcts and leukoaraiosis. In the other an old small left frontal infarct was also present. In both moderate cortical atrophy co-existed.

CONCLUSIONS

We hypothesize that co-existing lesions, possibly associated with a sub-clinical reduction of cognitive functions, facilitate the development of a persistent clinically evident mental deficit after the occurrence of an infarct in the capsular genu.

Discourse priming of homophones in individuals with dominant nonthalamic subcortical lesions, cortical lesions and Parkinson's disease

An on-line priming experiment was used to investigate discourse-level processing in four matched groups of subjects: individuals with nonthalamic subcortical lesions (NSL) (n = 10), normal control subjects (n = 10), subjects with Parkinson's disease (PD) (n = 10), and subjects with cortical lesions (n = 10). Subjects listened to paragraphs that ended in lexical ambiguities, and then made speeded lexical decisions on visual letter strings that were: nonwords, matched control words, contextually appropriate associates of the lexical ambiguity, contextually inappropriate associates of the ambiguity, and inferences (representing information which could be drawn from the paragraphs but was not explicitly stated). Targets were presented at an interstimulus interval (ISI) of 0 or 1000 ms. NSL and PD subjects demonstrated priming for appropriate and inappropriate associates at the short ISI, similar to control subjects and cortical lesion subjects, but were unable to demonstrate selective priming of the appropriate associate and inference words at the long ISI. These results imply intact automatic lexical processing and a breakdown in discourse-based meaning selection and inference development via attentional/strategic mechanisms.

Correlation of aphasia and/or neglect with cortical infarction in a subpopulation of RANTTAS

Classically in neurology, aphasia and neglect were accepted as reliable markers of cortical lesions. The actual prognostic values of aphasia and neglect have yet to be formally tested. This analysis sought to determine the predictive accuracy of aphasia and/or neglect in acute stroke for cortical infarction. Data from the RANTTAS investigation of tirilazad mesylate in stroke patients were reanalyzed, comparing acute National Institutes of Health Stroke Scale (NIHSS) measures of aphasia and neglect to lesion location on day 7-10 CT scans. Correlations between the presence of aphasia and/or neglect and the presence of a cortical lesion were only in the moderate range, and positive predictive values were far from perfect, as would be expected. 'Subcortical' aphasia or neglect was more likely in large, subcortical lesions. Aphasia and neglect, as determined in the acute setting by the NIHSS, are only moderately associated with cortical infarct identified on follow-up CT scans. If selective neuroprotection is envisioned for acute stroke patients, more accurate markers of cortical infarction may be needed.

A "cure" for chronic combat-related posttraumatic stress disorder secondary to a right frontal lobe infarct: a case report

A 48-year-old combat veteran sustained a right frontal cerebral infarct at the age of 45 years. The patient's family reports that prior to the infarct he had a preoccupation with memories of combat, as well as nightmares, avoidance of reminders, and multiple arousal symptoms. Since his recovery from the infarct, the patient and his family continue to relate significant arousal symptoms but deny any continued history of preoccupation with traumatic memories, reminder avoidance, or nightmares. The resolution of a limited number of symptoms in this patient following damage to the right frontal cortex suggests that some of the symptoms of posttraumatic stress disorder may be amenable to current biological interventions.

Trophic factor secreting kidney cell lines: in vitro characterization and functional effects following transplantation in ischemic rats

Several kidney cell lines were investigated for their ability to produce glial cell line-derived neurotrophic factor (GDNF). Cell line-conditioned medium was analyzed using ELISA and two cell lines were identified which produce GDNF in physiologically active concentrations. ELISA analyses revealed that conditioned medium from these two cell lines also contained PDGF, bFGF, TGFbeta1 and TGFbeta2. Both of these cell lines were then transplanted into the striatal penumbra of rats, 1 h following middle cerebral artery occlusion. Behavioral testing revealed that both cell lines reduced the deficit associated with cerebral ischemia and reduced the infarct volume relative to controls. Reduction of infarct volume was likely achieved by the action of GDNF and/or other growth factors produced by the cells.

Poor school and cognitive functioning with silent cerebral infarcts and sickle cell disease

The authors evaluated education attainment and neuropsychological deficits in children with sickle cell disease (SCD) and silent cerebral infarcts. Children with silent infarcts had twice the rate of school difficulties as children without infarcts. Eighty percent of silent infarct cases had clinically significant cognitive deficits, whereas 35% had deficits in academic skills. Children with silent cerebral infarcts show high rates of poor educational attainment, cognitive deficits, and frontal lobe injury. Poor school performance in SCD is one indicator of silent infarcts.

Cerebrovascular and brain morphologic correlates of mild cognitive impairment in the National Heart, Lung, and Blood Institute Twin Study

OBJECTIVE

To evaluate the relative risk (RR) of mild cognitive impairment (MCI) associated with cerebrovascular risk factors and cerebrovascular-related brain changes.

DESIGN

Mild cognitive impairment was determined for the subjects of the prospective National Heart, Lung, and Blood Institute Twin Study. Quantitative measures of brain, white matter hyperintensity, cerebral infarction, apolipoprotein E genotype, and psychometric testing were obtained.

RESULTS

Subjects with MCI were older (73.5 +/- 3.0 vs 72.1 +/- 2.8 years), consumed less alcohol (3.7 +/- 5.8 vs 7.0 +/- 10.7 drinks per week), had greater white matter hyperintensity volumes (0.56% +/- 0.82% vs 0.25% +/- 0.34% of cranial volume), and had an increased prevalence of apolipoprotein E4 genotype (31.4% vs 19.2%) than normal subjects. White matter hyperintensity and the presence of the apolipoprotein E4 genotype were associated with a significantly increased risk for MCI. When all subjects were included in the analysis, alcohol consumption was associated with a reduced risk for MCI (RR = 0.93, P<.05). When subjects with a history of symptomatic cerebrovascular disease were excluded from the analysis, elevated midlife diastolic blood pressure was associated with an increased risk for MCI (RR = 1.70, P<.05).

CONCLUSIONS

Elevated midlife blood pressures, and the resulting increased white matter hyperintensities, increase the risk for MCI in a group of community-dwelling older men to at least the same degree as apolipoprotein E4 genotype. Given the common occurrence of elevations in midlife blood pressure, early and effective treatment may be warranted to prevent late-life brain abnormalities and MCI. Moreover, since many individuals with MCI progress to clinical dementia, longitudinal evaluations of this cohort will be important.

Altitudinal neglect in a patient with occipital infarction

Visual neglect has been frequently described in a horizontal direction. Altitudinal neglect, however, has rarely been described and has been associated with bilateral lesions in the parieto-occipital or temporo-occipital region. The following case report presents a patient with marked altitudinal neglect of the inferior space which was elicited using a line bisection test. The previously healthy patient had well-defined lesions solely in the occipital cortex following an embolic infarction. The present case report underlines the possibility that bioccipital lesions themselves can be responsible for altitudinal neglect.

Secondary mania after ventral pontine infarction

Secondary mania is increasingly recognized clinically, and consists of acute exhibition of manic symptoms without past or family history of affective disorder. It has been reported with toxic and metabolic disturbances, primary and metastatic brain tumors, epilepsy, and cerebrovascular events. A multifactorial etiology has been suggested. We report two men, 52 and 56 years old, who developed grandiosity, sleeplessness, irritable mood, hyperactivity, and paranoid and religious delusions, with attempted violence in one case. Both had no premorbid psychiatric history and were healthy except for hypertension. One patient had a normal neurologic examination, and the other had mild left hemiparesis and hyperreflexia. EEGs, brainstem auditory-evoked responses, and median nerve somatosensory-evoked potentials were normal. Magnetic resonance studies demonstrated infarction of the ventral pons (on the right in the patient with left-sided signs and on the left in the patient with normal neurologic examination). The two patients responded to lithium carbonate and neuroleptics and have not had further psychiatric symptoms in 18 months of follow-up. These cases emphasize the relationship of late-onset mania with predisposing brain disease, and they suggest that brainstem disturbances can influence mood, sleep, libido, and thought.

[Memory disturbance caused by medial temporal lesion]

The memory disturbance caused by medial temporal lesion is reported concerning 6 cases of cerebral hemorrhage, infarction, brain tumor, and contusion. The memory disturbance was significant compared with the patient's intact orientation and normal intelligence. In the category of memory, recent memory was more markedly disturbed than the immediate or remote memory. From the viewpoint of the lesion, the memory disturbance was more severe when, in addition to the hippocampus, the entorhinal gyrus or amygdala was damaged. The visual memory disturbance was mild and no difference was observed in the verbal or visual memory according to whether the lesion was right or left. The memory disturbance was usually transient and marked improvement was observed in some cases.

How can cerebral infarcts and hemorrhages lead to dementia?

The incidence of new onset dementias is increased after stroke. The objective of this review is to investigate how cerebral infarcts and hemorrhages can lead to dementia. Stroke subtypes, total volume of cerebral lesion and functional tissue loss, and location of the lesions are the major determinant of dementia in stroke patients. The causal relationship between stroke and dementia is clear: (1) in young patients who are unlikely to have associated Alzheimer pathology; (2) when the cognitive functioning was normal before stroke, impaired immediately after, and does not worsen over time; (3) when the lesions are located in strategic areas; and (4) when a well-defined vasculopathy known to be associated with dementia is proven. However, white matter changes and associated Alzheimer pathology may also contribute to the dementia syndrome in stroke patients.

Gerstmann syndrome in systemic lupus erythematosus: neuropsychological, neuroimaging and spectroscopic findings

Gerstmann syndrome (GS) comprises four interlaced neuropsychological symptoms including finger agnosia, right-left confusion, agraphia, and acalculia. While GS is commonly associated with focal lesions to the region of the left angular gyrus, it has also been associated with numerous diffuse etiologies including atrophy, alcoholism, carbon monoxide poisoning, lead intoxication and anaphylactic shock. Thus, a vigorous debate has emerged as to whether GS represents a syndrome arising from general brain decline or a distinct and localizing lesion. We report a right-handed patient who developed neuropsychological dysfunction secondary to systemic lupus erythematosus (SLE). Neuropsychological evaluation found the patient to exhibit symptoms consistent with the GS tetrad, as well as general cognitive decline. Magnetic resonance imaging revealed a distinct focal lesion of the left parieto-occipital white matter underlying the angular gyrus as well as diffuse atrophy. (1)H-magnetic resonance spectroscopy revealed substantial metabolic derangement in a voxel placed within the visible lesion, although substantial metabolic derangement was observed in regions remote from the focal pathology. Thus, GS in this first case in SLE would appear to comprise a focal neurological tetrad of disorders within a more general pattern of cognitive decline and metabolic derangement.

Localization of hemiachromatopsia

Impaired color perception with relative preservation of form vision (achromatopsia) caused by cerebral lesions was first described over a century ago. However, for many years some researchers questioned the existence of an area of cerebral cortex apart from the primary visual cortex specialized in color processing. The development of sophisticated structural and functional neuroimaging techniques has allowed verification of the cortical structures important in color perception. We describe a case of a patient with impaired color perception in one hemifield of vision (hemiachromatopsia) and compare the localization of the lesion with previous cases described in the literature. These cases show that lesions of the ventromedial occipital cortex can impair color perception and leave form vision intact.

Word-centred neglect dyslexia: evidence from a new case

Neglect dyslexia resulting from damage to word-centred representations is extremely rare. We report on a new case. A left-handed subject, SVE, presented with aphasia and neglect dyslexia/dysgraphia following a right hemisphere stroke. In tachistoscopic reading tasks, some of his errors resulted from retina-centred neglect, as he responded more accurately to words flashed in the left visual field than to words flashed in the right visual field. However, the critical aspects of his reading performance indicated word-centred neglect. SVE incorrectly produced the initial elements of four-letter words, regardless of stimulus location (to the left and to the right of fixation, or at fixation), and orientation (horizontal and vertical presentation). A similar distribution of errors was demonstrated in writing (very inaccurate performance on initial letters). This pattern of performance suggests damage to an abstract letter string representation defined by spatial coordinates, rather than to an ordering mechanism. It is most naturally accommodated by models of word recognition which assume a word-centred level of representation, and cannot be explained by models which do not include such a representational level. Consideration of our subject in the light of other similar reports prompts hypotheses on the neural mechanisms involved in computing word-centred representations.

Hemispheric specialisation for self-paced motor sequences

Temporal aspects of motor control were investigated in patients with infarction to the brain with two finger-tapping tests. In the self-paced tapping task patients with cortical left-hemispheric lesions were slowed down and patients with left-hemispheric subcortical injuries were consistently faster as compared with control subjects and patients with right hemispheric cortical lesions. The results point to the dominant control of the left-hemisphere in voluntarily timed action and to a special time range of 250-300 ms involved in motor behaviour.

Phonological agraphia following a focal anterior insulo-opercular infarction

Following a unique infarction, restricted to the left anterior insula and the adjacent part of the intrasylvian frontal opercular cortex, an 83-year-old right-handed patient acutely developed a severe speech disorder that evolved into mere mutism within a few hours. After rapid recovery from mutism, oral language was characterized by severe apraxia of speech. In-depth language investigations further disclosed an isolated, highly selective disturbance of the spelling system (phonological agraphia) which resolved rapidly. One year after onset of neurological symptoms, the apraxia of speech had almost completely receded. The anatomoclinical findings in this first representative of pure and nearly isolated phonological agraphia complement previous neuroanatomical and neurolinguistic accounts of phonological agraphia. The data not only seem to enrich current insights in the anatomical locus for phonological agraphia, they also seem to contribute to a further delineation of the insular role in phonologically mediated aphasic manifestations.

[Anosognosia for hemiplegia in a patient with pontine infarction]

We report a patient with anosognosia for hemiplegia associated with a right pontine infarction. A 51-year-old woman with histories of hypertension and diabetes mellitus was admitted because of weakness of her left upper and lower extremities. On neurologic examination, she was alert and oriented without dementia. Visuospatial hemineglect was not present. Hemiparesis of her left upper and lower extremities was noted. Her brain MRIs showed a large infarction in the right pons. On admission, she could recognize her illness but was indifferent to her hemiplegia, so she said that there was not well-off for her life. Two weeks after the onset, her neurological symptoms gradually improved. Simultaneously, her interest in her hemiparesis increased. We proposed that, in the present patient, anosognosia for hemiplegia was caused by the pontine infarction. Since pontine anosognosia for hemiplegia has been rarely reported to date, it is expected that the findings of the present patient will be useful to the better understanding of mechanisms underlying anosognosia.