Recovery of function processes in human amnesia: evidence from transient global amnesia

The remains of the day: neuropsychological findings in postacute transient global amnesia

INTRODUCTION

Current clinical diagnostic criteria of transient global amnesia (TGA) require the episode to completely resolve within 24 h. Small case series investigating the neuropsychological profiles obtained during the first days after TGA are inconclusive, with some suggesting the persistence of memory deficits.

METHODS

In this retrospective observational study, neuropsychological data of 185 TGA patients obtained during the first days following an attack were analysed. Data of cognitive functions assessed in at least 50 patients were evaluated and dichotomised according to z-values as "impaired" or "unimpaired". Moreover, the results of magnetic resonance imaging (MRI) were collected.

RESULTS

Neuropsychological assessment was performed within the first 3 days after TGA in 158 (85.4%) of all patients. The majority of patients showed no significant neuropsychological sequelae in the postacute phase of TGA. However, Mini-Mental Status Examination showed impairment in 22.6% of 159 patients, and we found subtle reductions of patients' performance in tests of verbal long-term memory and executive function in 16.3-24.6% of patients. Patients with hippocampal diffusion-weighted imaging (DWI) lesions performed significantly worse in a verbal recognition task than those without DWI lesions.

DISCUSSION

Our findings reflect subtle performance reductions in different cognitive domains in a small subgroup of TGA patients. This implies that the gradual resolution of subclinical symptoms may take longer than the 24 h required as maximum episode duration by current diagnostic criteria.

The transience and nature of cognitive impairments in transient global amnesia: a meta-analysis

Transient global amnesia (TGA) is a clinical syndrome characterized by the sudden onset of severe amnesia without concomitant focal neurological symptoms. This meta-analysis of the cognitive characteristics of TGA addressed two main issues. First, we examined the hypothesis that the acute phase of TGA is associated with changes of anterograde and retrograde episodic long-term memory sparing semantic and short-term memory, while we had no clear prediction for potential reductions of executive functions due to the relative lack of previous studies addressing this issue. Second, we analyzed the time-course of changes in cognitive functions throughout three time intervals--acute (0-24 hours after TGA onset), postacute (24 hours to 5 days), and long-term phase (5-30 days)--to reveal whether there is a fast versus a delayed recovery. The results of the meta-analysis on 152 effect sizes from 25 studies showed that TGA is characterized by an extraordinarily large reduction of anterograde (d* = 1.89) and a somewhat milder reduction of retrograde (d* = 1.28) episodic long-term memory. Moreover, our results indicate the existence of additional, nonamnestic cognitive changes during TGA, because executive functions were also diminished (d* = 0.79). Reductions in both anterograde episodic long-term memory and executive function recover slowly, as slightly poorer performance in these cognitive domains can be found in the postacute phase (d*s = 0.32 and 0.44). All cognitive diminutions resolved within the long-term phase, by this calling into question previous reports of poorer performance of TGA patients relative to comparison subjects weeks or months after the attack.

The role of the hippocampus in long-term memory: is it memory store or comparator?

Several attempts have been made to reconcile a number of rival theories on the role of the hippocampus in long-term memory. Those attempts fail to explain the basic effects of the theories from the same point of view. We are reviewing the four major theories, and shall demonstrate, with the use of mathematical models of attention and memory, that only one theory is capable of reconciling all of them by explaining the basic effects of each theory in a unified fashion, without altogether sacrificing their individual contributions. The key issue here is whether or not a memory trace is ever stored in the hippocampus itself, and there is no reconciliation unless the answer to that question is that there is not. As a result of the reconciliation that we are proposing, there is a simple solution to several outstanding problems concerning the neurobiology of memory such as: consolidation and reconsolidation, persistency of long term memory, novelty detection, habituation, long-term potentiation, and the multifrequency oscillatory self-organization of the brain.

The dynamic time course of memory recovery in transient global amnesia

AIMS

To investigate the dynamic time course of transient global amnesia (TGA)--that is, the process of recovery and the interindividual variability--by testing four patients during the day of TGA itself (on three occasions) and at follow up (on two occasions).

METHODS

A specially designed protocol focusing on semantic (both conceptual and autobiographical knowledge) and episodic (both anterograde and retrograde components) memory.

RESULTS

Every patient showed marked impairment of both anterograde and retrograde episodic memory during the acute phase, with a relative preservation of personal and conceptual semantic knowledge. During the following phase, the authors observed similarities and differences among the patients' patterns of recovery. In general, retrograde amnesia recovered before the anterograde amnesia and anterograde episodic memory was recovered gradually in every case. In contrast, shrinkage of retrograde amnesia was more heterogeneous. In two of the patients, this shrinkage followed a chronological gradient and the most remote events were recovered first. In the two other patients, it depended more on the strength of the trace, and there was no temporal gradient. For the latter, an executive deficit could account for difficulties in accessing both conceptual knowledge and autobiographical memories.

CONCLUSIONS

This profile of recovery suggests a "neocortical to medial temporal" process in every case, and the possibility of an additional frontal dysfunction in some cases. Hence, the acute phase seems to be characterised by a common episodic impairment. This variability between subjects appears in the recovery phase with two different patterns of impairment.

The loss of episodic memories in retrograde amnesia: single-case and group studies

Retrograde amnesia in neurological disorders is a perplexing and fascinating research topic. The severity of retrograde amnesia is not well correlated with that of anterograde amnesia, and there can be disproportionate impairments of either. Within retrograde amnesia, there are various dissociations which have been claimed-for example, between the more autobiographical (episodic) and more semantic components of memory. However, the associations of different types of retrograde amnesia are also important, and clarification of these issues is confounded by the fact that retrograde amnesia seems to be particularly vulnerable to psychogenic factors. Large frontal and temporal lobe lesions have been postulated as critical in producing retrograde amnesia. Theories of retrograde amnesia have encompassed storage versus access disruption, physiological processes of 'consolidation', the progressive transformation of episodic memories into a more 'semantic' form, and multiple-trace theory. Single-case investigations, group studies and various forms of neuroimaging can all contribute to the resolution of these controversies.

Continuing cognitive impairment after isolated transient global amnesia

Fourteen patients were investigated 3-4 days after end of their transient global amnesia (TGA) with a number of neuropsychological tests. Their performance was compared with that of a control group, matched for age, education, and profession. It was found that in spite of the common definition of TGA, impairments in both verbal and non-verbal long term memory and verbal fluency persisted and were in fact impaired to such a degree that it seemed unlikely that full recovery would have occurred within the next few days. We propose a major role of stress in the etiology and the recovery process of TGA and consider it likely that stress hormones are of major influence both in the triggering of TGA and the subsequent continuation of cognitive impairments.

Functional neuroanatomy of amnesia: positron emission tomography studies

In this article, we review the principles of, and provide examples for, the new approach of functional neuropsychology in the field of amnesia. In the permanent amnesic syndrome, positron emission tomography (PET) can provide statistical maps of the brain regions with significantly impaired resting metabolism in comparison with control subjects. These regions include not only Papez's circuit but also the left supramarginal gyrus, which may explain in part the retrograde amnesia present in most cases of amnesic syndrome. This approach is also of great interest in transient global amnesia (TGA) because the defect of episodic memory is highly selective and occurs without permanent damage. The few available PET studies in TGA suggest the dysfunction of a distributed network including the hippocampal region and the prefrontal cortex, with a different pattern individually. Further studies will be necessary to better understand the relationships between the precise cognitive deficits in TGA and the pattern of brain hypometabolism. In Alzheimer's disease (AD), the study of the correlations between memory test scores and metabolic values across a sample of subjects provides a map of those brain structures whose synaptic pathology dysfunction underlies the particular neuropsychological alteration. The distribution of the sites of correlations shows striking differences according to each memory system. This approach should open the way for the unravelling of the neurobiological substrates of both cognitive impairment and compensatory mechanisms in neurodegenerative diseases. Over and above their applications in neurological research, such studies in brain-diseased subjects are particularly useful for establishing cognitive and neurobiological models of human memory, because they allow the highlighting of the neural networks that are essential for memory function. From a cognitive neuroscience perspective, the functional neuropsychology of amnesia is, therefore, complementary to the classic activation paradigm in normal subjects, which identifies the cerebral structures that are involved with, but not necessarily indispensable for, the execution of the task.

Transient amnesia triggered by acute marijuana intoxication

We report an unusual case of sudden isolated transient amnesia triggered by acute marijuana use. The memory disorder, apart from the long duration, had the characteristics of a transient global amnesia-like episode. Acute marijuana intoxication can affect memory more globally and severely than previously reported.