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Altunkalem Seydi K, Kaya D, Yavuz I, Ontan MS, Dost FS, Isik AT. Primitive reflexes and dementia in older adults: a meta-analysis of observational and cohort studies. Psychogeriatrics 2024; 24:688-700. [PMID: 38400649 DOI: 10.1111/psyg.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
Primitive reflexes (PRs) are clinical signs that indicate diffuse cerebral dysfunction and frontal lesions. We aimed to present a comprehensive analysis of the prevalence and risk of PRs in patients with dementia. English-language articles published from January 1990 to April 2021 were searched in PubMed, ScienceDirect, Cochrane, and Web of Science with keywords. The titles and abstracts of the identified articles were screened to identify potentially relevant papers. Odds ratios and risk ratios were extracted with 95% confidence intervals and combined using the random-effects model after logarithmic transformation. The prevalence in dementia patients was also combined using the random-effects model. This meta-analysis involved 29 studies. The snout reflex (48% of cases) was the most prevalent. It was found that the risk of PRs in individuals with dementia was significantly elevated, ranging from 13.94 to 16.38 times higher than in healthy controls. The grasp reflex exhibited the highest risk for dementia. This meta-analysis showed that the prevalence and the risk of PRs is high in older patients with dementia. Therefore, PRs, especially the grasp reflex, should be carefully assessed as a part of routine physical examination in the diagnostic process for dementia.
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Affiliation(s)
- Kübra Altunkalem Seydi
- Unit for Ageing Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Derya Kaya
- Unit for Ageing Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Idil Yavuz
- Department of Statistics, Dokuz Eylul University, Faculty of Science, Izmir, Turkey
| | - Mehmet Selman Ontan
- Unit for Ageing Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Fatma Sena Dost
- Department of Geriatric Medicine, Darica Farabi Training and Research Hospital, Kocaeli, Turkey
| | - Ahmet Turan Isik
- Unit for Ageing Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Zhou M, Li Y. Effect of different doses of almorexant on learning and memory in 8-month-old APP/PS1 (AD) mice. Peptides 2023; 167:171044. [PMID: 37330110 DOI: 10.1016/j.peptides.2023.171044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To explore the effects of different doses of almorexant (an dual orexin receptor antagonist) on learning and memory in Alzheimer's disease (AD) mice. METHODS Forty-four APP/PS1 (model of Alzheimer's disease; AD) mice were randomly divided into 4 groups: the control group (CON) and those that received 10mg/kg almorexant (low dose; LOW), 30mg/kg almorexant (medium dose; MED) and 60mg/kg almorexant (high dose; HIGH). During the 28-day intervention period, mice received an intraperitoneal injection at the beginning of the light period (6:00 am). The effects of different doses of almorexant on learning and memory and 24-hour sleep-wake behaviour were assessed by immunohistochemical staining. The above continuous variables are expressed as the mean ± standard deviation (SD), and then univariate regression analysis and generalized estimating equations were performed to compare the groups; these results are expressed as the mean difference (MD) and 95% confidence interval (CI). The statistical software used STATA 17.0 MP. RESULTS Forty-one mice completed the experiment (3 died: 2 mice in the HIGH group and 1 mouse in the CON group). Compared with the CON group, the LOW group (MD=6,803s, 95% CI: 4,470 to 9,137s), MED group (MD=14,473s, 95% CI: 12,140 to 16,806s) and the HIGH group (MD=24,505s, 95% CI: 22,052 to 26,959s) had significantly longer sleep durations. The Y maze results showed that LOW group (MD=0.14,95%CI: 0.078 to 0.20) and MED group (MD=0.14,95%CI = 0.074 to 0.20) mice compared to the CON group, and the low-medium dose of Almorexant did not damage the short-term learning and memory performance of APP / PS1 (AD) mice.Compared with the CON, LOW, and MED groups, the HIGH group exhibited a significant decrease in the Aβ plaque-positive area in the cortex (MD= -0.030, 95% CI: -0.035 to -0.025; MD=-0.049, 95% CI: -0.054 to -0.044; and MD=-0.07, 95% CI: -0.076 to -0.066, respectively). CONCLUSION The moderate dose of almorexant (30mg/kg) prolonged the sleep duration of APP/PS1 (AD) mice to a greater extent than the low dose (10mg/kg) without altering learning and memory. The MED mice showed a good sleep response and a small residual effect on the next day. High-dose (60mg / kg) almorexant impaired behavioral learning and memory performance in mice.Compared to the CON group and the LOW group, the MED group exhibited improved working memory. Thus, treatment with almorexant may reduce β-amyloid deposition in AD, slowing neurodegeneration. Additional studies are needed to determine the mechanism of action.
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Affiliation(s)
- Mengzhen Zhou
- Department of Neurology, Qianfo Mountain Hospital affiliated to Shandong First Medical University ,Jinan, Shandong, China.
| | - Yanran Li
- Department of Neurology, Qianfo Mountain Hospital affiliated to Shandong First Medical University, Jinan, Shandong, China
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Yao K, Wang J, Ma B, He L, Zhao T, Zou X, Weng Z, Yao R. A nomogram for predicting risk of death during hospitalization in elderly patients with Alzheimer's disease at the time of admission. Front Neurol 2023; 14:1093154. [PMID: 36873432 PMCID: PMC9978216 DOI: 10.3389/fneur.2023.1093154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023] Open
Abstract
Background and objectives Elderly patients with Alzheimer's disease (AD) often have multiple underlying disorders that lead to frequent hospital admissions and are associated with adverse outcomes such as in-hospital mortality. The aim of our study was to develop a nomogram to be used at hospital admission for predicting the risk of death in patients with AD during hospitalization. Methods We established a prediction model based on a dataset of 328 patients hospitalized with AD -who were admitted and discharged from January 2015 to December 2020. A multivariate logistic regression analysis method combined with a minimum absolute contraction and selection operator regression model was used to establish the prediction model. The identification, calibration, and clinical usefulness of the predictive model were evaluated using the C-index, calibration diagram, and decision curve analysis. Internal validation was evaluated using bootstrapping. Results The independent risk factors included in our nomogram were diabetes, coronary heart disease (CHD), heart failure, hypotension, chronic obstructive pulmonary disease (COPD), cerebral infarction, chronic kidney disease (CKD), anemia, activities of daily living (ADL) and systolic blood pressure (SBP). The C-index and AUC of the model were both 0.954 (95% CI: 0.929-0.978), suggesting that the model had accurate discrimination ability and calibration. Internal validation achieved a good C-index of 0.940. Conclusion The nomogram including the comorbidities (i.e., diabetes, CHD, heart failure, hypotension, COPD, cerebral infarction, anemia and CKD), ADL and SBP can be conveniently used to facilitate individualized identification of risk of death during hospitalization in patients with AD.
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Affiliation(s)
- Kecheng Yao
- Department of Geriatrics, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Junpeng Wang
- Department of Geriatrics, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Baohua Ma
- Department of Medical Record, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Ling He
- Department of General Practice, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Tianming Zhao
- Department of Respiratory and Critical Care Medicine, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Xiulan Zou
- Department of Geriatrics, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Zean Weng
- Department of Neurology, The First College of Clinical Medical Sciences, Three Gorges University, Yichang, Hubei, China
| | - Rucheng Yao
- Department of Hepatopancreatobilary Surgery, The First College of Clinical Medical Sciences, Three Gorges University, Yichang, Hubei, China
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MacKenzie JL, Ivanova N, Nell HJ, Giordano CR, Terlecky SR, Agca C, Agca Y, Walton PA, Whitehead SN, Cechetto DF. Microglial inflammation and cognitive dysfunction in comorbid rat models of striatal ischemic stroke and alzheimer’s disease: effects of antioxidant catalase-SKL on behavioral and cellular pathology. Neuroscience 2022; 487:47-65. [DOI: 10.1016/j.neuroscience.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/25/2022]
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Scheffler M, Salomir R, Maturana E, Montandon ML, Kövari EV, Haller S. Identification of hippocampal cortical microinfarcts on postmortem 3-T magnetic resonance imaging. Neuroradiology 2021; 63:1569-1573. [PMID: 33909116 PMCID: PMC8376696 DOI: 10.1007/s00234-021-02717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Abstract
Cortical microinfarcts (CMI) are increasingly recognized in the neurological community as a biomarker related to cognitive impairment and dementia. If their radiological depiction has been largely described in experimental settings using ultra-high-field magnetic resonance imaging (MRI), less is known about their visibility on routinely used 3-T MRI. In this radiologic-pathologic correlation study, using 3-T post-mortem MRI, we searched for hippocampal CMI, in a double-blinded fashion, and found that only 4/36, or 11%, were clearly demonstrated on both radiological and histopathological exams.
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Affiliation(s)
- Max Scheffler
- Division of Radiology, Geneva University Hospitals, Chemin du Pont-Bochet 3, 1226, Thonex, Switzerland.
| | - Rares Salomir
- Image Guided Interventions Laboratory, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.,Division of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Enrique Maturana
- Division of Radiology, Geneva University Hospitals, Chemin du Pont-Bochet 3, 1226, Thonex, Switzerland
| | - Marie-Louise Montandon
- Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Route de Loëx 151, 1233, Bernex, Switzerland.,Department of Psychiatry, Geneva University Hospitals, Chemin du Petit Bel-Air 2, 1225, Chene-Bourg, Switzerland
| | - Enikö V Kövari
- Department of Psychiatry, Geneva University Hospitals, Chemin du Petit Bel-Air 2, 1225, Chene-Bourg, Switzerland
| | - Sven Haller
- CIMC - Centre d'Imagerie Médicale de Cornavin, Place de Cornavin 18, 1201, Geneva, Switzerland.,Radiology, Department of Surgical Sciences, Uppsala University, 75236, Sjukhusvägen, Sweden
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Van Dam D, Vermeiren Y, Dekker AD, Naudé PJW, Deyn PPD. Neuropsychiatric Disturbances in Alzheimer's Disease: What Have We Learned from Neuropathological Studies? Curr Alzheimer Res 2017; 13:1145-64. [PMID: 27137218 PMCID: PMC5070416 DOI: 10.2174/1567205013666160502123607] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/04/2016] [Accepted: 04/27/2016] [Indexed: 12/16/2022]
Abstract
Neuropsychiatric symptoms (NPS) are an integral part of the dementia syndrome and were therefore recently included in the core diagnostic criteria of dementia. The near universal prevalence of NPS in Alzheimer's disease (AD), combined with their disabling effects on patients and caregivers, is contrasted by the fact that few effective and safe treatments exist, which is in part to be attributed to our incomplete understanding of the neurobiology of NPS. In this review, we describe the pathological alterations typical for AD, including spreading and evolution of burden, effect on the molecular and cellular integrity, functional consequences and atrophy of NPS-relevant brain regions and circuits in correlation with specific NPS assessments. It is thereby clearly established that NPS are fundamental expressions of the underlying neurodegenerative brain disease and not simply reflect the patients' secondary response to their illness. Neuropathological studies, moreover, include a majority of end-stage patient samples, which may not correctly represent the pathophysiological environment responsible for particular NPS that may already be present in an early stage, or even prior to AD diagnosis. The burdensome nature and high prevalence of NPS, in combination with the absence of effective and safe pharmacotherapies, provide a strong incentive to continue neuropathological and neurochemical, as well as imaging and other relevant approaches to further improve our apprehension of the neurobiology of NPS.
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Affiliation(s)
| | | | | | | | - Peter P De Deyn
- Laboratory of Neurochemistry and Behaviour, Institute Born-Bunge, Department of Biomedical Sciences, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, and, Faculty of Medical and Health Care Sciences, University of Antwerp, Universiteitsplein 1, BE-2610 Wilrijk (Antwerp), Belgium
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Corrada MM, Sonnen JA, Kim RC, Kawas CH. Microinfarcts are common and strongly related to dementia in the oldest-old: The 90+ study. Alzheimers Dement 2016; 12:900-8. [PMID: 27243907 DOI: 10.1016/j.jalz.2016.04.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/08/2016] [Accepted: 04/27/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION We estimated the prevalence of microinfarcts and their association with dementia in a cohort of oldest-old participants. METHODS Participants were from The 90+ Study, a population-based study of people 90 years and older. Dementia diagnoses were assigned postmortem during a consensus conference. Microinfarcts were evaluated in six brain regions. RESULTS At death, the 213 participants were on average 97 years old, 69% were women, and 52% had dementia. Of the participants, 51% had microinfarcts and 17% had 3+ microinfarcts. The odds ratio (OR) for dementia was similar for 3+ microinfarcts (OR = 4.75, P < .01) and tangle stage V-VI (OR = 4.70, P < .001). Only microinfarcts in cortical regions (other than occipital) were associated to dementia. DISCUSSION In this oldest-old cohort, microinfarcts are common and contribute independently and similarly in magnitude to dementia as tangles. As risk factors for microinfarcts and other dementing pathologies are likely to differ, identifying these factors is crucial to developing prevention strategies for dementia in the oldest-old.
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Affiliation(s)
- María M Corrada
- Department of Neurology, University of California, Irvine, CA, USA; Department of Epidemiology, University of California, Irvine, CA, USA.
| | - Joshua A Sonnen
- Department of Pathology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Ronald C Kim
- Department of Pathology, University of California, Irvine, CA, USA
| | - Claudia H Kawas
- Department of Neurology, University of California, Irvine, CA, USA; Department of Neurobiology & Behavior, University of California, Irvine, CA, USA
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Bien-Ly N, Boswell CA, Jeet S, Beach TG, Hoyte K, Luk W, Shihadeh V, Ulufatu S, Foreman O, Lu Y, DeVoss J, van der Brug M, Watts RJ. Lack of Widespread BBB Disruption in Alzheimer's Disease Models: Focus on Therapeutic Antibodies. Neuron 2016; 88:289-97. [PMID: 26494278 DOI: 10.1016/j.neuron.2015.09.036] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 09/08/2015] [Accepted: 09/17/2015] [Indexed: 12/21/2022]
Abstract
The blood-brain barrier (BBB) limits brain uptake of therapeutic antibodies. It is believed that the BBB is disrupted in Alzheimer's disease (AD), potentially increasing drug permeability de facto. Here we compared active versus passive brain uptake of systemically dosed antibodies (anti-transferrin receptor [TfR] bispecific versus control antibody) in mouse models of AD. We first confirmed BBB disruption in a mouse model of multiple sclerosis as a positive control. Importantly, we found that BBB permeability was vastly spared in mouse models of AD, including PS2-APP, Tau transgenics, and APOE4 knockin mice. Brain levels of TfR in mouse models or in human cases of AD resembled controls, suggesting target engagement of TfR bispecific is not limited. Furthermore, infarcts from human AD brain showed similar occurrences compared to age-matched controls. These results question the widely held view that the BBB is largely disrupted in AD, raising concern about assumptions of drug permeability in disease.
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Affiliation(s)
- Nga Bien-Ly
- Department of Neuroscience, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA.
| | - C Andrew Boswell
- Department of Development Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Surinder Jeet
- Department of Translational Immunology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Thomas G Beach
- Banner Sun Health Research Institutes, 10515 West Santa Fe Drive, Sun City, AZ 85372, USA
| | - Kwame Hoyte
- Department of Biochemical and Cellular Pharmacology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Wilman Luk
- Department of Biochemical and Cellular Pharmacology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Vera Shihadeh
- Department of Biochemical and Cellular Pharmacology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Sheila Ulufatu
- Department of Development Sciences, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Oded Foreman
- Department of Pathology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Yanmei Lu
- Department of Biochemical and Cellular Pharmacology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Jason DeVoss
- Department of Translational Immunology, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Marcel van der Brug
- Department of Diagnostic Discovery, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA.
| | - Ryan J Watts
- Department of Neuroscience, Genentech Inc., 1 DNA Way, South San Francisco, CA 94080, USA
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Abstract
The older patient population is growing rapidly around the world and in the USA. Almost half of seniors over age 65 who live at home are dissatisfied with their sleep, and nearly two-thirds of those residing in nursing home facilities suffer from sleep disorders. Chronic and pervasive sleep complaints and disturbances are frequently associated with excessive daytime sleepiness and may result in impaired cognition, diminished intellect, poor memory, confusion, and psychomotor retardation all of which may be misinterpreted as dementia. The key sleep disorders impacting patients with dementia include insomnia, hypersomnolence, circadian rhythm misalignment, sleep disordered breathing, motor disturbances of sleep such as periodic leg movement disorder of sleep and restless leg syndrome, and parasomnias, mostly in the form of rapid eye movement (REM) sleep behavior disorder (RBD). RBD is a pre-clinical marker for a class of neurodegenerative diseases, the "synucleinopathies", and requires formal polysomnographic evaluation. Untreated sleep disorders may exacerbate cognitive and behavioral symptoms in patients with dementia and are a source of considerable stress for bed partners and family members. When left untreated, sleep disturbances may also increase the risk of injury at night, compromise health-related quality of life, and precipitate and accelerate social and economic burdens for caregivers.
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Affiliation(s)
- Verna R Porter
- Department of Neurology, UCLA Mary S. Easton Center for Alzheimer's Disease Research, David Geffen School of Medicine at UCLA, 10911 Weyburn Ave., Suite 200, Los Angeles, CA, 90095-7226, USA.
| | - William G Buxton
- Department of Neurology, David Geffen School of Medicine at UCLA, 300 UCLA Medical Plaza, Suite B200, Los Angeles, CA, 90095-6975, USA.
| | - Alon Y Avidan
- Department of Neurology, UCLA Sleep Disorders Center, David Geffen School of Medicine at UCLA, 710 Westwood Blvd., Room 1-145 RNRC, Los Angeles, CA, 90095-1769, USA.
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Isolated hippocampal infarcts: Vascular and neuropsychological findings. J Neurol Sci 2015; 356:83-9. [PMID: 26142022 DOI: 10.1016/j.jns.2015.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE The hippocampus plays a role in the verbal and spatial memory processing, learning, and emotions. The purpose of this study was to determine clinical, etiological, and radiological features of isolated hippocampal infarcts. METHODS We reviewed, 6800 patients with first-ever ischaemic stroke included in our Stroke Registry between 2004 and 2014. Among them we studied 19 patients with an acute isolated hippocampal infarct confirmed by MRI. RESULTS Among 6800 patients, 19 patients (0.03%) showed ischaemic lesions in the hippocampal artery territory, allowing us to delineate 5 variant distributions; (1) anterior hippocampal infarcts (4 patients [21%]) were present with altered consciousness, transient visual vivid hallucinations, and transient global amnesia with episodic and verbal memory deficits. (2) Posterior hippocampal infarcts (3 patients [16%]) developed dizziness and dullness at stroke onset, confusion, episodic and procedural memory deficit and verbal learning deficit. (3) Unilateral complete hippocampal infarcts were present (4 patients [21%]) with confusion, object specific hallucinations, intense mood states changes as well as impulsivity or depressive behaviour. Memory dysfunctions were found in all patients. (4) Bilateral hippocampal infarcts (3 patients [16%]) had cognitive deficits and memory deficits in all patients. All patients had difficulties retrieving specific autobiographical events and retrieving recent memory, and disturbances of learning in verbal and visual task. Hippocampal dementia was observed in 2 patients with severe immediate, delayed verbal and visual memory deficits, dysexecutive syndrome, deficits in responding to feedback and error correction with dull and aimless appearance lasting several months. (5) Small circumscribed (punctiform) hippocampal infarcts (5 patients [26%]) showed dizziness or dullness sensation and difficulties finding words or objects that they use everyday. Cardioembolism (10; 53%) and large-artery disease of the vertebrobasilar system (6; 32%) were the main stroke mechanisms. CONCLUSIONS We described topographic patterns of hippocampal infarction with distinct manifestations and etiologies. We thought that different patterns of hippocampal infarcts are the result of variation in hippocampal arterial supply or reflect a source of embolism.
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Vemuri P, Lesnick TG, Przybelski SA, Knopman DS, Preboske GM, Kantarci K, Raman MR, Machulda MM, Mielke MM, Lowe VJ, Senjem ML, Gunter JL, Rocca WA, Roberts RO, Petersen RC, Jack CR. Vascular and amyloid pathologies are independent predictors of cognitive decline in normal elderly. ACTA ACUST UNITED AC 2015; 138:761-71. [PMID: 25595145 PMCID: PMC4339775 DOI: 10.1093/brain/awu393] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Vemuri et al. show that amyloid and vascular pathologies are independent processes, and that both are major drivers of cognitive decline in the elderly. Cognitive reserve as measured by educational/occupational level and mid/late-life cognitive activity seems to offset the deleterious effects of both pathologies on cognitive trajectories. Our primary objective was to investigate a biomarker driven model for the interrelationships between vascular disease pathology, amyloid pathology, and longitudinal cognitive decline in cognitively normal elderly subjects between 70 and 90 years of age. Our secondary objective was to investigate the beneficial effect of cognitive reserve on these interrelationships. We used brain amyloid-β load measured using Pittsburgh compound B positron emission tomography as a marker for amyloid pathology. White matter hyperintensities and brain infarcts were measured using fluid-attenuated inversion recovery magnetic resonance imaging as a marker for vascular pathology. We studied 393 cognitively normal elderly participants in the population-based Mayo Clinic Study of Aging who had a baseline 3 T fluid-attenuated inversion recovery magnetic resonance imaging assessment, Pittsburgh compound B positron emission tomography scan, baseline cognitive assessment, lifestyle measures, and at least one additional clinical follow-up. We classified subjects as being on the amyloid pathway if they had a global cortical amyloid-β load of ≥1.5 standard uptake value ratio and those on the vascular pathway if they had a brain infarct and/or white matter hyperintensities load ≥1.11% of total intracranial volume (which corresponds to the top 25% of white matter hyperintensities in an independent non-demented sample). We used a global cognitive z-score as a measure of cognition. We found no evidence that the presence or absence of vascular pathology influenced the presence or absence of amyloid pathology and vice versa, suggesting that the two processes seem to be independent. Baseline cognitive performance was lower in older individuals, in males, those with lower education/occupation, and those on the amyloid pathway. The rate of cognitive decline was higher in older individuals (P < 0.001) and those with amyloid (P = 0.0003) or vascular (P = 0.0037) pathologies. In those subjects with both vascular and amyloid pathologies, the effect of both pathologies on cognition was additive and not synergistic. For a 79-year-old subject, the predicted annual rate of global z-score decline was −0.02 if on neither pathway, −0.07 if on the vascular pathway, −0.08 if on the amyloid pathway and −0.13 if on both pathways. The main conclusions of this study were: (i) amyloid and vascular pathologies seem to be at least partly independent processes that both affect longitudinal cognitive trajectories adversely and are major drivers of cognitive decline in the elderly; and (ii) cognitive reserve seems to offset the deleterious effect of both pathologies on the cognitive trajectories.
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Affiliation(s)
- Prashanthi Vemuri
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Timothy G Lesnick
- 2 Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Scott A Przybelski
- 2 Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - David S Knopman
- 3 Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Greg M Preboske
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Kejal Kantarci
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Mekala R Raman
- 3 Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Mary M Machulda
- 4 Department of Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Michelle M Mielke
- 2 Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Val J Lowe
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Matthew L Senjem
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Jeffrey L Gunter
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Walter A Rocca
- 2 Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA 3 Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Rosebud O Roberts
- 2 Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Ronald C Petersen
- 3 Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Clifford R Jack
- 1 Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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Abstract
Unilateral cerebral ischemia of the hippocampus is very rare. This paper reviews the literature and presents the case of a 59-year-old woman with an amnestic syndrome due to a left hippocampal stroke. The patient suffered from retrograde amnesia which was most severe over the 2 days prior to presenting and a slight anterograde amnesia. In addition, a verbal memory disorder was confirmed 1 week after admission by neurological tests. As risk factors, arterial hypertension and a relative hyper-beta lipoproteinemia were found. This case shows that unilateral amnestic stroke, e.g. in the hippocampus region, may be the cause of an amnestic syndrome and should be included in the differential diagnostics.
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Affiliation(s)
- J D Rollnik
- Institut für neurorehabilitative Forschung (InFo) der BDH-Klinik Hessisch Oldendorf gGmbH, Neurologisches Zentrum mit Intensivmedizin, Stroke Unit und phasenübergreifender Rehabilitation, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover (MHH), Greitstr. 18-28, 31840, Hessisch Oldendorf, Deutschland,
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13
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Brainin M, Tuomilehto J, Heiss WD, Bornstein NM, Bath PMW, Teuschl Y, Richard E, Guekht A, Quinn T. Post-stroke cognitive decline: an update and perspectives for clinical research. Eur J Neurol 2014; 22:229-38, e13-6. [PMID: 25492161 DOI: 10.1111/ene.12626] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 10/17/2014] [Indexed: 01/12/2023]
Abstract
The close relationship between stroke and dementia is an important health issue. Ischaemic stroke can facilitate the onset of vascular dementia as well as aggravate pre-existing cognitive decline. The onset of cognitive decline may become manifest immediately following the onset of ischaemic stroke, but often there is a delay in the development of cognitive decline after a stroke. This delay can be seen as a therapeutic time window allowing interventions to be applied to preserve cognition following stroke. Both neurodegenerative and vascular mechanisms are activated and probably result in overlapping processes within the neurovascular unit. This review focuses on the incidence and prevalence of cognitive decline following stroke, predisposing stroke aetiologies, pre-stroke decline, imaging factors and biomarkers. Outcomes are discussed in relation to timing of assessment and neuropsychological tests used for evaluation of cognitive decline in ischaemic stroke patients. Including such tests in routine evaluations of stroke patients after some weeks or months is recommended. Finally, an outlook on ongoing and planned intervention trials is added and some recommendations for future research are proposed.
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Affiliation(s)
- M Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
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14
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Jellinger KA. Pathogenesis and treatment of vascular cognitive impairment. Neurodegener Dis Manag 2014; 4:471-90. [DOI: 10.2217/nmt.14.37] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
SUMMARY Vascular cognitive impairment (VCI) defines a continuum of disorders ranging from mild cognitive impairment to full-blown dementia, attributable to cerebrovascular causes. Major morphological types – multi-infarct encephalopathy, strategic infarct type, subcortical arteriosclerotic leukoencephalopathy, multilacunar state, postischemic encephalopathy – result from systemic, cardiac and local large or small vessel disease. Cognitive decline is commonly caused by widespread small cerebrovascular lesions (CVLs) affecting regions/networks essential for cognition, memory and behavior. CVLs often coexist with Alzheimer-type and other pathologies, which interact in promoting dementia, but in many nondemented elderly individuals, mixed brain pathologies are also present. Due to the high variability of CVLs, no validated clinical and neuropathological criteria for VCI are available. Cholinesterase inhibitors and memantine produce small cognitive improvement but without essential effect. Antihypertensive treatment, cardiovascular control and lifestyle modifications reducing vascular risk factors are essential. Given its growing health, social and economic burden, prevention and treatment of VCI are a major challenge of neuroscience.
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15
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Thiel A, Cechetto DF, Heiss WD, Hachinski V, Whitehead SN. Amyloid burden, neuroinflammation, and links to cognitive decline after ischemic stroke. Stroke 2014; 45:2825-9. [PMID: 25005439 DOI: 10.1161/strokeaha.114.004285] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Alexander Thiel
- From the Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada (A.T.); Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology (D.F.C., S.N.W.), and Department of Clinical Neurological Sciences, London Health Sciences Centre (V.H., S.N.W.), Western University, London, Ontario, Canada; and Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.)
| | - David F Cechetto
- From the Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada (A.T.); Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology (D.F.C., S.N.W.), and Department of Clinical Neurological Sciences, London Health Sciences Centre (V.H., S.N.W.), Western University, London, Ontario, Canada; and Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.)
| | - Wolf-Dieter Heiss
- From the Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada (A.T.); Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology (D.F.C., S.N.W.), and Department of Clinical Neurological Sciences, London Health Sciences Centre (V.H., S.N.W.), Western University, London, Ontario, Canada; and Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.)
| | - Vladimir Hachinski
- From the Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada (A.T.); Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology (D.F.C., S.N.W.), and Department of Clinical Neurological Sciences, London Health Sciences Centre (V.H., S.N.W.), Western University, London, Ontario, Canada; and Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.)
| | - Shawn N Whitehead
- From the Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada (A.T.); Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology (D.F.C., S.N.W.), and Department of Clinical Neurological Sciences, London Health Sciences Centre (V.H., S.N.W.), Western University, London, Ontario, Canada; and Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.).
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16
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Jellinger KA. Pathology and pathogenesis of vascular cognitive impairment-a critical update. Front Aging Neurosci 2013; 5:17. [PMID: 23596414 PMCID: PMC3622231 DOI: 10.3389/fnagi.2013.00017] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/24/2013] [Indexed: 12/21/2022] Open
Abstract
Vascular cognitive impairment (VCI) [vascular cognitive disorder (VCD), vascular dementia] describes a continuum of cognitive disorders ranging from mild cognitive impairment (MCI) to dementia, in which vascular brain injury involving regions important for memory, cognition and behavior plays an important role. Clinical diagnostic criteria show moderate sensitivity (ca 50%) and variable specificity (range 64-98%). In Western clinical series, VaD is suggested in 8-10% of cognitively impaired elderly subjects. Its prevalence in autopsy series varies from 0.03 to 58%, with means of 8 to 15% (in Japan 22-35%). Major types of sporadic VaD are multi-infarct encephalopathy, small vessel and strategic infarct type dementias, subcortical arteriosclerotic leukoencephalopathy (SAE) (Binswanger), multilacunar state, mixed cortico-subcortical type, granular cortical atrophy (rare), postischemic encephalopathy, and a mixture of cerebrovascular lesions (CVLs). They result from systemic, cardiac and local large or small vessel disease (SVD); their pathogenesis is multifactorial. Hereditary forms of VaD caused by gene mutations are rare. Cognitive decline is commonly associated with widespread small ischemic vascular lesions involving subcortical brain areas (basal ganglia and hemispheral white matter). The lesions affect neuronal networks involved in cognition, memory, and behavior (thalamo-cortical, striato-subfrontal, cortico-subcortical, limbic systems). CVLs often coexist with Alzheimer-type lesions and other pathologies; 25-80% of elderly demented show mixed pathologies. The lesion pattern of "pure" VaD differs from that in mixed dementia (AD + CVLs) suggesting different pathogenesis of both phenotypes. Minor CVLs, except for severe amyloid angiopathy, appear not essential for cognitive impairment in full-blown AD, while both mild AD-type pathology and SVD may interact synergistically in promoting dementia. However, in a large percentage of non-demented elderly individuals, both AD-related and vascular brain pathologies have been reported. Despite recent suggestions for staging and grading CVLs in specific brain areas, due to the high variability of CVLs associated with cognitive impairment, no validated neuropathological criteria are currently available for VaD and mixed dementia. Further clinico-pathological studies and harmonization of neuropathological procedures are needed to validate the diagnostic criteria for VaD and mixed dementia in order to clarify the impact of CVLs and other coexistent pathologies on cognitive impairment as a basis for further successful therapeutic options.
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Affiliation(s)
- Kurt A. Jellinger
- Institute of Clinical Neurobiology, Medical University of ViennaVienna, Austria
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17
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Olazarán J, Navarro E, Rojo JM. Alzheimer's disease with vascular component: a distinct clinical entity? Dement Geriatr Cogn Dis Extra 2012; 2:400-10. [PMID: 23139685 PMCID: PMC3493007 DOI: 10.1159/000342346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Longitudinal reports on the clinical features of patients with Alzheimer's disease (AD) and concomitant cerebrovascular disease are scarce. Methods We elaborated a working definition of AD with vascular component (ADVC), and this definition was retrospectively investigated in a cohort of patients with cognitive deterioration who were prescribed a cholinesterase inhibitor during usual practice. Results A total of 137 patients with probable AD and 66 patients with ADVC were studied during a mean follow-up period of 2.8 years. Univariate analyses demonstrated worse functional evolution and anticipation of psychotic symptoms and agitation in the ADVC group. Conclusions The present results are consistent with an additive model of predominantly frontal-subcortical vascular damage in AD.
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Affiliation(s)
- Javier Olazarán
- Hermanos Sangro Specialties Clinic, Service of Neurology, Gregorio Marañón University Hospital, Spain ; Alzheimer Disease Research Unit, CIEN Foundation, Carlos III Institute of Health, Alzheimer Center Reina Sofía Foundation, Spain
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18
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Beynon R, Sterne JAC, Wilcock G, Likeman M, Harbord RM, Astin M, Burke M, Bessell A, Ben-Shlomo Y, Hawkins J, Hollingworth W, Whiting P. Is MRI better than CT for detecting a vascular component to dementia? A systematic review and meta-analysis. BMC Neurol 2012; 12:33. [PMID: 22672344 PMCID: PMC3403932 DOI: 10.1186/1471-2377-12-33] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 06/06/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Identification of causes of dementia soon after symptom onset is important, because appropriate treatment of some causes of dementia can slow or halt its progression or enable symptomatic treatment where appropriate. The accuracy of MRI and CT, and whether MRI is superior to CT, in detecting a vascular component to dementia in autopsy confirmed and clinical cohorts of patients with VaD, combined AD and VaD ("mixed dementia"), and AD remain unclear. We conducted a systematic review and meta-analysis to investigate this question. METHODS We searched eight databases and screened reference lists to identify studies addressing the review question. We assessed study quality using QUADAS. We estimated summary diagnostic accuracy according to imaging finding, and ratios of diagnostic odds ratios (RDORs) for MRI versus CT and high versus low risk of bias. RESULTS We included 7 autopsy and 31 non-autopsy studies. There was little evidence that selective patient enrolment and risk of incorporation bias impacted on diagnostic accuracy (p = 0.12 to 0.95). The most widely reported imaging finding was white matter hyperintensities. For CT (11 studies) summary sensitivity and specificity were 71% (95% CI 53%-85%) and 55% (44%-66%). Corresponding figures for MRI (6 studies) were 95% (87%-98%) and 26% (12%-50%). General infarcts was the most specific imaging finding on MRI (96%; 95% CI 94%-97%) and CT (96%; 93%-98%). However, sensitivity was low for both MRI (53%; 36%-70%) and CT (52%; 22% to 80%). No imaging finding had consistently high sensitivity. Based on non-autopsy studies, MRI was more accurate than CT for six of seven imaging findings, but confidence intervals were wide. CONCLUSION There is insufficient evidence to suggest that MRI is superior to CT with respect to identifying cerebrovascular changes in autopsy-confirmed and clinical cohorts of VaD, AD, and 'mixed dementia'.
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Affiliation(s)
- Rebecca Beynon
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Jonathan A C Sterne
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Gordon Wilcock
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Marcus Likeman
- Frenchay Hospital, Beckspool Road, Bristol, BS16 1LE, UK
| | - Roger M Harbord
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Margaret Astin
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Margaret Burke
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Alysson Bessell
- School of Oral and Dental Sciences, University of Bristol, Lower Maudlin Street, Bristol, BS1 2LY, UK
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - James Hawkins
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - William Hollingworth
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Penny Whiting
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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19
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Rauramaa T, Pikkarainen M, Englund E, Ince PG, Jellinger K, Paetau A, Parkkinen L, Alafuzoff I. Cardiovascular diseases and hippocampal infarcts. Hippocampus 2012; 21:281-7. [PMID: 20054813 DOI: 10.1002/hipo.20747] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
UNLABELLED The prevalence of hippocampal lesions such as hippocampal infarcts have not been studied in detail even though hippocampal alterations are known to be associated with various clinical conditions such as age-related degenerative disorders and epilepsy. METHODS Here we defined the hippocampal infarcts and assessed the prevalence of this lesion in large unselected population of 1,245 subjects age ranging from 1 to 99 years (mean age 79 ± 1 S.E.M). Furthermore, we assessed the association of these lesions with various cardio- and cerebro-vascular disorders and other neurodegenerative lesions. The prevalence of hippocampal infarct in the study population of 1,245 subjects was 12%, increasing to 13% when only those with a clinically diagnosed cognitive impairment (n = 311) were analyzed. Large hemispheric brain infarcts were seen in 31% of the study subjects and these lesions were strongly associated with cardiovascular risk factors such as hypertension (43%), coronary disease (32%), myocardial infarct (22%), atrial fibrillation (20%), and heart failure (20%). In contrast, hippocampal infarcts displayed a significant association only with large hemispheric brain infarct, heart failure, and cardiovascular index as assessed postmortem. It is noteworthy that only widespread hippocampal infarcts were associated with clinical symptoms of cognitive impairment or epilepsy. The surprisingly low prevalence of 12% of hippocampal infarcts in aged population found here and the failure to detect an association between this lesion and various cerebro- cardio-vascular lesions is intriguing. Whether susceptibility to ischemia in line with susceptibility to neuronal degeneration in this region is influenced by still undetermined risk- factors need further investigation. Furthermore it should be noted that the size of the hippocampal tissue damage, i.e., small vs. large cystic infarcts is of significance regarding clinical alterations.
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Affiliation(s)
- Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital, Finland
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20
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Abstract
Vascular cognitive impairment is an umbrella term for cognitive dysfunction associated with and presumed to be caused by vascular brain damage. Autopsy studies have identified microinfarcts as an important neuropathological correlate of vascular cognitive impairment that escapes detection by conventional magnetic resonance imaging (MRI). As a frame of reference for future high-resolution MRI studies, we systematically reviewed the literature on neuropathological studies on cerebral microinfarcts in the context of vascular disease, vascular risk factors, cognitive decline and dementia. We identified 32 original patient studies involving 10,515 people. The overall picture is that microinfarcts are common, particularly in patients with vascular dementia (weighted average 62%), Alzheimer's disease (43%), and demented patients with both Alzheimer-type and cerebrovascular pathology (33%) compared with nondemented older individuals (24%). In many patients, multiple microinfarcts were detected. Microinfarcts are described as minute foci with neuronal loss, gliosis, pallor, or more cystic lesions. They are found in all brain regions, possibly more so in the cerebral cortex, particularly in watershed areas. Reported sizes vary from 50 μm to a few mm, which is within the detection limit of current high-resolution MRI. Detection of these lesions in vivo would have a high potential for future pathophysiological studies in vascular cognitive impairment.
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21
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Smith EE, Schneider JA, Wardlaw JM, Greenberg SM. Cerebral microinfarcts: the invisible lesions. Lancet Neurol 2012; 11:272-82. [PMID: 22341035 PMCID: PMC3359329 DOI: 10.1016/s1474-4422(11)70307-6] [Citation(s) in RCA: 329] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The association between small but still visible lacunar infarcts and cognitive decline has been established by population-based radiological and pathological studies. Microscopic examination of brain sections shows even smaller but substantially more numerous microinfarcts, the focus of this Review. These lesions often result from small vessel pathologies such as arteriolosclerosis or cerebral amyloid angiopathy. They typically go undetected in clinical-radiological correlation studies that rely on conventional structural MRI, although the largest acute microinfarcts can be detected by diffusion-weighted imaging. In view of their high numbers and widespread distribution, microinfarcts could directly disrupt important cognitive networks and thus account for some of the neurological dysfunction associated with lesions visible on conventional MRI such as lacunar infarcts and white matter hyperintensities. Standardised neuropathological assessment criteria and the development of non-invasive means of detection during life would be major steps towards understanding the causes and consequences of otherwise macroscopically invisible microinfarcts.
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Affiliation(s)
- Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie A. Schneider
- Departments of Pathology and Neurological Sciences, Rush Alzheimer’s Disease Centre, Rush University Medical Center, Chicago, IL, USA
| | - Joanna M. Wardlaw
- Centre for Cognitive Ageing and Cognitive Epidemiology (CCACE), University of Edinburgh, UK,Scottish Imaging Network, A Platform for Scientific Excellence (SINAPSE) Collaboration
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22
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Chen W, Song X, Zhang Y. Assessment of the Virchow-Robin Spaces in Alzheimer disease, mild cognitive impairment, and normal aging, using high-field MR imaging. AJNR Am J Neuroradiol 2011; 32:1490-5. [PMID: 21757525 PMCID: PMC7964361 DOI: 10.3174/ajnr.a2541] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 12/30/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE VRSs are the perivascular spaces surrounding the deep perforating arteries in the brain. Although VRS variations with age and disease pathologies have been reported previously, the radiologic characteristics of the VRS in relation to AD are poorly understood. This study investigated the prevalence, spatial distribution, and severity of the VRS in AD, MCI, and older adults who were CN. It also investigated the relationship of the VRS to white matter changes. MATERIALS AND METHODS Structural MR imaging data were acquired from 158 participants (AD = 37, MCI = 71, CN = 50, mean age = 74.97 ± 7.20 years) who had undergone T1WI at 3T. The severity of VRS in the white matter, basal ganglia, hippocampus, and brain stem structures was evaluated by using a semiquantitative scale, adapted from existing rating scales. A VRS total score summarizing the subscales was calculated to assess the whole-brain VRSs. RESULTS VRSs were observed in multiple brain regions of all participants, typically presented as <2-mm well-margined symmetric round-, oval- and linear-shaped hypointensities on T1WI. The VRS total score increased with leukoaraiosis, atrophy, and advanced age (P < .001). Individuals with AD and MCI showed greater levels of VRS than control subjects. The VRS total score discriminated individuals with AD and those who were CN with an accuracy of 0.79 (95% CI, 0.69-0.89). CONCLUSIONS VRSs are common in older adults and are more severe in AD and MCI than in CN. Whether increased VRSs can be reliably used to aid in AD diagnosis warrants further investigation.
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Affiliation(s)
- W Chen
- Department of Radiology, General Hospital of Tianjin Medical University, China
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Cho SJ, Scarmeas N, Jang TW, Marder K, Tang MX, Honig LS. Importance of symptomatic cerebral infarcts on cognitive performance in patients with Alzheimer's disease. J Korean Med Sci 2011; 26:412-6. [PMID: 21394311 PMCID: PMC3051090 DOI: 10.3346/jkms.2011.26.3.412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 12/10/2010] [Indexed: 11/29/2022] Open
Abstract
The coexistence of cerebral infarcts and Alzheimer's disease (AD) is common, but the influence of symptomatic cerebral infarcts on cognition is uncertain in AD. We hypothesize that symptomatic cerebral infarcts may provide an additive cognitive factor contributing to dementia in the AD population. We studied 1,001 clinically probable or possible AD patients in the Alzheimer Disease Research Center (ADRC) database. Linear regression was used to evaluate for an association between symptomatic cerebral infarcts and memory, language, executive function, abstract reasoning, and visuospatial performance, separately. Models were adjusted for covariates including age, gender, education, ethnicity, hypertension, diabetes mellitus, heart disease, clinical dementia rating, the presence of silent cerebral infarcts, and multiplicity or location of infarcts. Clinical history of stroke was present in 107 patients, radiological infarcts in 308 patients, and 68 patients with both were considered to have symptomatic infarcts. Adjusting for all covariates, AD patients with symptomatic infarcts had more impairment of executive function (P < 0.05). The influence of cerebral infarcts is neither general nor diffuse, and the presence of clinical history may have a more important influence on executive performance in AD.
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Affiliation(s)
- Soo-Jin Cho
- Department of Neurology, Hangang Sacred Heart Hospital, Hallym University College of Medicine, 12 Beodnamu-ro 7-gil, Seoul, Korea.
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Berlow YA, Wells WM, Ellison J, Sung YH, Renshaw PF, Harper DG. Neuropsychiatric correlates of white matter hyperintensities in Alzheimer's disease. Int J Geriatr Psychiatry 2010; 25:780-8. [PMID: 19946864 PMCID: PMC3975914 DOI: 10.1002/gps.2418] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate the association of behavioral and psychological symptoms of dementia (BPSD) in Alzheimer's disease (AD) and magnetic resonance imaging (MRI) measures of brain atrophy and white matter hyperintensities (WMH). METHODS Thirty-seven patients with probable AD received the Neuropsychiatric Inventory (NPI), the Mini Mental Status Exam (MMSE), and an MRI scan as part of their initial evaluation at the Outpatient Memory Diagnostic Clinic at McLean Hospital. MRI-based volumetric measurements of whole brain atrophy, hippocampal volumes, and WMH were obtained. Analysis of covariance models, using age as a covariate and the presence of specific BPSD as independent variables, were used to test for differences in whole brain volumes, hippocampal volumes and WMH volumes. RESULTS Increased WMH were associated with symptoms of anxiety, aberrant motor behavior, and night time disturbance, while symptoms of disinhibition were linked to lower WMH volume. No associations were found for whole brain or hippocampal volumes and BPSD. CONCLUSIONS These findings suggest that white matter changes are associated with the presence of BPSD in AD.
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Affiliation(s)
- Yosef A. Berlow
- Geriatric Psychiatry Program, McLean Hospital, Belmont,
MA,Psychiatry, Harvard Medical School, Boston, MA
| | - William M. Wells
- Radiology, Brigham and Women's Hospital, Boston,
MA,Radiology, Harvard Medical School, Boston, MA,Computer Science and Artificial Intelligence Laboratory,
Massachusetts Institute of Technology, Cambridge, MA
| | - James Ellison
- Geriatric Psychiatry Program, McLean Hospital, Belmont,
MA,Psychiatry, Harvard Medical School, Boston, MA
| | - Young Hoon Sung
- Brain Imaging Center, McLean Hospital, Belmont, MA,Psychiatry, Harvard Medical School, Boston, MA
| | - Perry F. Renshaw
- Brain Imaging Center, McLean Hospital, Belmont, MA,Psychiatry, Harvard Medical School, Boston, MA
| | - David G. Harper
- Geriatric Psychiatry Program, McLean Hospital, Belmont,
MA,Psychiatry, Harvard Medical School, Boston, MA
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25
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Jellinger KA, Attems J. Prevalence of dementia disorders in the oldest-old: an autopsy study. Acta Neuropathol 2010; 119:421-33. [PMID: 20204386 DOI: 10.1007/s00401-010-0654-5] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 02/03/2010] [Accepted: 02/06/2010] [Indexed: 02/06/2023]
Abstract
The prevalence of Alzheimer disease (AD) and vascular dementia (VD) increases with advancing age, but less so after age 90 years. A retrospective hospital-based study of the relative prevalence of different disorders was performed in 1,110 consecutive autopsy cases of demented elderly in Vienna, Austria (66% females, MMSE <20; mean age 83.3 +/- 5.4 SD years). It assessed clinical, general autopsy data and neuropathology including immunohistochemistry. Neuropathologic diagnosis followed current consensus criteria. Four age groups (7-10th decade) were evaluated. In the total cohort AD pathology was seen in 82.9% ("pure" AD 42.9%; AD + other pathologies 39.9%), VD in 10.8% (mixed dementia, MIX, i.e. AD + vascular encephalopathy in 5.5%); other disorders in 5.7%, and negative pathology in 0.8%. The relative prevalence of AD increased from age 60 to 89 years and decreased slightly after age 90+, while "pure" VD diagnosed in the presence of vascular encephalopathy of different types with low neuritic AD pathology (Braak stages <3; mean 1.2-1.6) decreased progressively from age 60 to 90+; 85-95% of these patients had histories of diabetes, morphologic signs of hypertension, 65% myocardial infarction/cardiac decompensation, and 75% a history of stroke(s). Morphologic subtypes, subcortical arteriosclerotic (the most frequent), multi-infarct encephalopathy, and strategic infarct dementia showed no age-related differences. The relative prevalence of AD + Lewy pathology remained fairly constant with increasing age. Mixed dementia and AD with minor cerebrovascular lesions increased significantly with age, while other dementias decreased. This retrospective study using strict morphologic criteria confirmed increased prevalence of AD with age, but mild decline at age 90+, and progressive decline of VD, while AD + vascular pathologies including MIX showed considerable age-related increase, confirming that mixed pathologies account for most dementia cases in very old persons. A prospective clinicopathologic study in oldest-old subjects showed a significant increase in both AD and cerebral amyloid angiopathy (CAA), but decrease in VD over age 85, while in a small group of old subjects CAA without considerable AD pathology may be an independent risk factor for cognitive decline.
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26
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Szabo K, Förster A, Jäger T, Kern R, Griebe M, Hennerici MG, Gass A. Hippocampal Lesion Patterns in Acute Posterior Cerebral Artery Stroke. Stroke 2009; 40:2042-5. [DOI: 10.1161/strokeaha.108.536144] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Reports of ischemic stroke affecting the hippocampus are rare. In this study we used diffusion-weighted MRI (DWI) to characterize patients with posterior circulation stroke involving the hippocampus.
Methods—
Fifty-seven consecutive acute stroke patients with hippocampal infarct (HI) on DWI were analyzed with regard to clinical features and ischemic lesion patterns. The last 20 of these underwent additional neuropsychological testing of short-term, working, and episodic long-term memory.
Results—
We found unilateral HI in 54 and bilateral HI in 3 patients. Visual analysis identified 4 patterns of DWI lesion affecting (1) the complete hippocampus (15/60), (2) the lateral (19/60) or (3) dorsal (22/60) parts of the hippocampal body and tail, and (4) circumscribed lesions in the lateral hippocampus (4/60), corresponding well to hippocampal vascular anatomy. In all cases DWI showed further ischemic lesions in the posterior circulation. Symptoms from lesions outside the hippocampus were the common leading clinical signs. Whereas mnestic deficits were prominent in only 11/57 patients, neuropsychological examination in 20 patients showed deficits of verbal episodic long-term memory in left and of nonverbal episodic long-term memory in right HI.
Conclusion—
Several phenotypic lesion patterns can be distinguished in HI that usually occur as part of multifocal PCA ischemia. A careful neuropsychological examination is necessary to detect resulting memory deficits.
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Affiliation(s)
- Kristina Szabo
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Alex Förster
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theodor Jäger
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Rolf Kern
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Griebe
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael G. Hennerici
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
| | - Achim Gass
- From the Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
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Giannakopoulos P, Kövari E, Herrmann FR, Hof PR, Bouras C. Interhemispheric distribution of Alzheimer disease and vascular pathology in brain aging. Stroke 2008; 40:983-6. [PMID: 19118241 DOI: 10.1161/strokeaha.108.530337] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Most of the neuropathological studies in brain aging were based on the assumption of a symmetrical right-left hemisphere distribution of both Alzheimer disease and vascular pathology. To explore the impact of asymmetrical lesion formation on cognition, we performed a clinicopathological analysis of 153 cases with mixed pathology except macroinfarcts. METHODS Cognitive status was assessed prospectively using the Clinical Dementia Rating scale; neuropathological evaluation included assessment of Braak neurofibrillary tangle and Ass deposition staging, microvascular pathology, and lacunes. The right-left hemisphere differences in neuropathological scores were evaluated using the Wilcoxon signed rank test. The relationship between the interhemispheric distribution of lesions and Clinical Dementia Rating scores was assessed using ordered logistic regression. RESULTS Unlike Braak neurofibrillary tangle and Ass deposition staging, vascular scores were significantly higher in the left hemisphere for all Clinical Dementia Rating scores. A negative relationship was found between Braak neurofibrillary tangle, but not Ass staging, and vascular scores in cases with moderate to severe dementia. In both hemispheres, Braak neurofibrillary tangle staging was the main determinant of cognitive decline followed by vascular scores and Ass deposition staging. The concomitant predominance of Alzheimer disease and vascular pathology in the right hemisphere was associated with significantly higher Clinical Dementia Rating scores. CONCLUSIONS Our data show that the cognitive impact of Alzheimer disease and vascular lesions in mixed cases may be assessed unilaterally without major information loss. However, interhemispheric differences and, in particular, increased vascular and Alzheimer disease burden in the right hemisphere may increase the risk for dementia in this group.
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28
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Understanding hippocampal sclerosis in the elderly: epidemiology, characterization, and diagnostic issues. Curr Neurol Neurosci Rep 2008; 8:363-70. [PMID: 18713571 DOI: 10.1007/s11910-008-0057-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hippocampal sclerosis (HS) is a pathologic term used to describe severe loss of neurons and reactive gliosis without cystic cavitation in the CA1 sector of the hippocampus. In late life, HS is associated with hippocampal atrophy, severe amnesia, and slowly progressive dementia without clinical seizure activity. HS is difficult to distinguish clinically from Alzheimer's disease and is often diagnosed postmortem. In autopsy series, HS may be found without significant other pathology (2%-4% of cases), but it occurs frequently in combination with other vascular and neurodegenerative disorders (12%-20% of cases). HS is found bilaterally in 50% of cases and unilaterally in 50% of cases, with similar predilection for the right versus left hemisphere. The pathogenesis of HS is unknown and may be multifactorial in origin, possibly due to anoxic/ischemic injury or TDP-43-related neurodegeneration. Little is known about the prevention and treatment of late-life HS, although circumstantial evidence suggests the importance of identifying and treating vascular risk factors.
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29
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Jellinger KA. Morphologic diagnosis of “vascular dementia” — A critical update. J Neurol Sci 2008; 270:1-12. [DOI: 10.1016/j.jns.2008.03.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 03/07/2008] [Accepted: 03/13/2008] [Indexed: 01/24/2023]
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McDonald RJ, Craig LA, Hong NS. Enhanced cell death in hippocampus and emergence of cognitive impairments following a localized mini-stroke in hippocampus if preceded by a previous episode of acute stress. Eur J Neurosci 2008; 27:2197-209. [DOI: 10.1111/j.1460-9568.2008.06151.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Modrego PJ, Rios C, Pérez Trullen JM, Errea JM, García-Gómara MJ, Sanchez S. The cerebrovascular pathology in Alzheimer's disease and its influence on clinical variables. Am J Alzheimers Dis Other Demen 2008; 23:91-6. [PMID: 18276961 PMCID: PMC10846270 DOI: 10.1177/1533317507309274] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vascular pathology is frequently found in the brains of patients with Alzheimer's disease (AD). The aim of this study is to assess the frequency of vascular pathology in the brain in AD patients in a systematic manner and its clinical significance at presentation. A series of 51 patients with mild to moderate AD were consecutively enrolled. At baseline, every patient underwent the following clinical scales: Mini-Mental, Clinical Dementia Rating Scale, Ischemic Scale, Blessed Dementia Rating Scale, Alzheimer's Disease Assessment Scale Cognitive Subscale, Neuropsychiatric Inventory, and an Activities of Daily Living Scale (Disability Assessment for Dementia). We also carried out magnetic resonance imaging of the brain and color echo Doppler of carotids to measure the intima-media thickness. White matter hyperintensities were quantitatively evaluated with the Wahlund scale. We did not find correlation between intima-media thicknesses of carotids and clinical scales and between the Wahlund scale and clinical scales. The presence or absence of both microinfarctions and hypertension had no influence in the scores of the clinical scales. We conclude that the vascular component is common in AD but only as coincident pathology.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain.
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Abstract
Mixed dementia (MD) refers to a combination of definite Alzheimer disease (AD) and vascular encephalopathy, but the distinction between both disorders is controversial. For the diagnosis of MD the clinical/neuroimaging criteria of possible AD plus cerebrovascular disease (CVD) as separate entities are used, but causal relations between vascular brain lesions and dementia are unclear. We proposed the combination of autopsy-proven AD with multiple vascular or ischemic lesions with about 30-50 ml of infarcted/damaged brain tissue. The population-based prevalence of MD is unknown. In retrospective and prospective autopsy studies, it ranges from 2 to 58% with reasonable means of 6-12%. In a consecutive autopsy series of 1500 demented elderly subjects, 830 of which with clinically probable AD, in Vienna, Austria, 41.5 to 52.0% showed "pure" AD, 7% atypical AD, 16-20% AD plus cerebrovascular lesions, and 9% AD plus Lewy body pathology; MD was diagnosed in 4.6 and 2.4%, and "pure" vascular dementia (VaD) in 11 and 2.0%, respectively, while 16.3/6.1% were other dementing disorders, and 1% showed no specific pathology. Like the MRC-CFAS and other studies, this indicates frequent coexistence of AD with multiple cerebrovascular lesions in cognitively impaired patients. In both AD and VaD, vascular lesions frequently involved subcortical regions (basal ganglia, thalamus, hippocampus, and white matter) or were multiple microinfarcts, whereas in MD, large/hemispheral infarcts and multiple microinfarcts were more frequent, suggesting different pathogenic mechanisms. In early/mild AD, critically located small vascular lesions may induce/promote cognitive decline, but in full-blown AD they appear of minor importance. Discussion of the major pathogenic factors inducing AD, VaD and MD suggests synergistic relations between these disorders. However, currently available morphological criteria for AD and VaD are of limited value for the diagnosis of MD and generally accepted and validated histopathological criteria for the diagnosis of VaD and MD are currently not available. Therefore, more distinct and critically evaluated clinico-pathological criteria are warranted.
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Affiliation(s)
- K A Jellinger
- Institute of Clinical Neurobiology, 18, Kenyongasse, A-1070 Vienna, Austria.
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Giannakopoulos P, Gold G, Kövari E, von Gunten A, Imhof A, Bouras C, Hof PR. Assessing the cognitive impact of Alzheimer disease pathology and vascular burden in the aging brain: the Geneva experience. Acta Neuropathol 2007; 113:1-12. [PMID: 17036244 DOI: 10.1007/s00401-006-0144-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 09/06/2006] [Accepted: 09/06/2006] [Indexed: 01/31/2023]
Abstract
The progressive development of Alzheimer disease (AD)-related lesions, such as neurofibrillary tangles (NFT), amyloid deposits and synaptic loss, and the occurrence of microvascular and small macrovascular pathology within the cerebral cortex are conspicuous neuropathologic features of brain aging. Recent neuropathologic studies strongly suggested that the clinical diagnosis of dementia depends more on the severity and topography of pathological changes than on the presence of a qualitative marker. However, several methodological problems, such as selection biases, case-control design, density-based measures and masking effects, of concomitant pathologies persisted. In recent years, we performed several clinicopathologic studies using stereological counting of AD lesions. In order to define the cognitive impact of lacunes and microvascular lesions, we also analyzed pure vascular cases without substantial AD pathology. Our data revealed that total NFT numbers in the CA1 field, cortical microinfarcts and subcortical gray matter lacunes were the stronger determinants of dementia. In contrast, the contribution of periventricular and subcortical white matter demyelinations had a modest cognitive effect even in rare cases with isolated microvascular pathology. Importantly, in cases with pure AD pathology, more than 50% of Clinical Dementia Rating scale variability was not explained by NFT, amyloid deposits and neuronal loss in the hippocampal formation. In cases with microvascular pathology or lacunes, this percentage was even lower. The present review summarizes our data in this field and discusses their relevance within the theoretical framework of the functional neuropathology of brain aging and with particular reference to the current efforts to develop standardized neuropathological criteria for mixed dementia.
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Affiliation(s)
- Panteleimon Giannakopoulos
- Division of Geriatric Psychiatry, Department of Psychiatry, University of Geneva School of Medicine, 1225 Chêne-Bourg, Geneva, Switzerland
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34
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Jellinger KA. The enigma of mixed dementia. Alzheimers Dement 2007; 3:40-53. [DOI: 10.1016/j.jalz.2006.09.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 09/22/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Kurt A. Jellinger
- Institute of Clinical Neurobiology; Kenyongasse 18, A-1070 Vienna Austria
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35
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Korczyn AD. Alzheimer's disease and vascular brain lesions. J Neurol Sci 2005; 231:1-2. [PMID: 15792813 DOI: 10.1016/j.jns.2004.11.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 11/22/2004] [Indexed: 11/28/2022]
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