[Treatment pattern of Alzheimer's disease with cholinesterase inhibitors (TRAIN study)]

AIMS

To describe the relation between the level of cognitive impairment in Alzheimer's disease and the use of cholinesterase inhibitors (ChEIs) in neurology, geriatric and psychiatric units, and to establish the clinical profile of these patients.

PATIENTS AND METHODS

An epidemiological, multi-centre, cross-sectional study was conducted. Subjects included in the study were consecutive outpatients diagnosed with Alzheimer's disease, in accordance with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, and who had been treated with rivastigmine, donepezil or galantamine, either on its own or in association with memantine in the last six months. The recruitment period lasted three months. In a single visit, researchers determined the medication that was used, the dose, the mini-mental test, the overall clinical impression-overall improvement and the overall clinical impression-severity of the disease. A total of 1940 patients were selected from neurology, psychiatric and geriatric services all over the country. Possible differences in the habits of different specialists as regards prescribing were analysed, together with the relation between cognitive impairment and the type of medication employed.

RESULTS

The mean age of the patients was 77 +/- 6.6 years, 62% of whom were females; the mean score on the mini-mental test was 17.4 +/- 5.5. The mini-mental score was similar in patients treated with rivastigmine (18.02 +/- 5.23), donepezil (17.08 +/- 5.54) or galantamine (17.34 +/- 5.38). In patients who were treated with memantine in association with a ChEI, the mini-mental score was significantly lower (11.44 +/- 5.68) (p < 0.0001). The doses of the different ChEIs used by the specialists were similar. A higher percentage of patients had maximum doses of donepezil (81%) than in the cases of rivastigmine (43%) and galantamine (67%).

CONCLUSIONS

The different specialists involved (neurologists, geriatricians and psychiatrists) displayed similar habits regarding the utilisation of ChEIs to treat Alzheimer's disease. There was no relation between the degree of impairment and the drug chosen, except in the case of memantine.

[Topographic disorientation associated with infarction in the territory of the right posterior cerebral artery]

INTRODUCTION

Topographic disorientation is defined as the difficulty to find one s way in familiar surroundings. It can be due to an amnesic or agnostic like defect, which is known as topographic amnesia or agnosia. This disorder can give rise to disability in the life of the patient and may well go undetected unless a suitable neuropsychological study is conducted.

CASE REPORTS

We report the cases of two patients with infarction in the territory of the right posterior cerebral artery who began with hemianopsia and topographic disorientation. One of the cases was due to a disorder affecting spatial memory and the other was caused by errors in visuospatial perception. The battery of tests for studying visuospatial perception VOSP was administered.

CONCLUSIONS

Occipital lesions are often associated with topographic disorientation, especially when it is the right hemisphere that is injured. It is important to detect this alteration, which makes the patient totally dependent on others even in his or her own home. The appearance of an amnesic or agnostic type disorientation can be related with a disorder affecting one of the two systems that play a part in the processing of visual data. A guided neuropsychological study can provide us with a great deal of information about the type of disorder presented by the patient.

Transient topographical disorientation

Transient topographical disorientation (TTD) is a short-lasting inability to find one's way in a familiar environment, while the patient remains conscious and is able to recall what happened. We report the study of 10 patients with episodes of TTD, studied on the days following the last episode. The episodes of TTD could be separated into two types: the patients either reported difficulties in spatial orientation with preserved abilities to recognize landmarks and objects, or the difficulties appeared with the recognition of landmarks. Tests exploring spatial orientation, as well as higher visuoperceptive capacities were altered in most of the patients and brain SPECT showed hypoperfusion of the right hemisphere in all patients, which could also be demonstrated 2 years later in some cases. Altogether, our findings suggest that TTD is frequently associated with a more persistent right hemisphere dysfunction of unknown cause. This chronic alteration could represent either a sequel of the acute episode or a preexisting right hemisphere deficit, which inclined the acute insult to be manifested as TTD.

[Alzheimer's disease and women]

INTRODUCTION AND DEVELOPMENT

This work reviews the relation between Alzheimer s disease (AD) and women, a very interesting issue both for its socio economic, and etiopathogenic and therapeutic aspects. Much of the prevalent research conducted in this field shows that a higher proportion of suffers from this disease are women, and in the work on incidence there is at least a tendency toward the same conclusion, especially at a very advanced age. In fact, the risk of suffering from AD is greater among women and most of the patients we attend are females, which is to a large extent associated with the fact that women live longer. However, it is possible that there are other biological factors involved and for this reason the action of estrogens on the brain and the consequences of women s being deprived of them during menopause is of special interest.

CONCLUSIONS

Different studies have shown that the administration of hormone replacement therapy (HRT) lowers the risk of suffering from this disease, although design defects make it necessary to wait for the conclusions from other research work currently being conducted. There are also data that supports the idea that HRT can be beneficial in AD if it is administered in suitable doses. Obviously gender can influence or modulate other risk factors (RF). Genetic factors are not easily modified and for this reason research is currently aimed at factors in which a strong environmental component is involved. Another very controversial possible RF is lack of schooling, but some data support the notion that its influence can be especially harmful among females. This is a very important hypothesis because women make up the greater part of the illiterate population in Spain. Finally, women are also prevalent among caregivers and, therefore, suffer AD from both angles: they must care and be cared for. The reaction to this situation seems to be gender specific, which means that women in particular suffer the consequences of the lack of reciprocity brought about by AD something that does not happen in other equally devastating chronic processes, but which affect the physical sphere.

[Spontaneous cerebral calcium embolism]

INTRODUCTION

Calcium embolism is an uncommon cause of stroke which may not be diagnosed in cases which do not involve cardiac surgery or catheterization. The emboli may come from cardiac valves or calcified atheroma of the aortic or carotid arteries.

CASE REPORTS

Two patients with cerebral infarcts secondary to spontaneous calcium embolism confirmed by neuro imaging. In both cases on CT scans there were dense points corresponding to calcified material within the middle cerebral artery or one of its branches. In the first case migration of the calcified point following the course of the artery was observed.

CONCLUSIONS

Cranial CAT scans are essential for diagnosis of calcium embolism. Migration of the calcified point confirms the diagnosis. It is still not clear whether valve replacement is necessary in these patients and treatment with antiaggregants and/or anticoagulants is controversial.

[Recurrent familial brachial plexopathy as the only clinical expression of neuropathy with susceptibility to pressure]

We report a family with hereditary neuropathy with liability to pressure palsies (HNPP) and chromosome 17p11.2 deletion. This family exhibits a peculiar phenotype consisting in recurrent brachial plexopathy episodes. This phenotype has to be distinguished from hereditary neuralgic amyotrophy on clinical grounds. Although the incidence of brachial plexopathy on HNPP is relatively high it is unusual as the sole symptom of the disease. It is noteworthy that in the six published families with this peculiar phenotype most of the acute episodes became evident after sleep. A greater liability of the plexus and a greater vulnerability to mechanical factors during sleep hours are the suggested mechanisms to explain this rare clinical onset. Recurrent painless brachial plexopathy when associated to generalized conduction abnormalities should suggest a HNPP.

[Psychotic symptoms and Alzheimer's disease]

BACKGROUND

Psychotic symptoms appear during the course of Alzheimer's disease, but their frequency and intensity vary according to different studies and their nature remains unsettled.

OBJECTIVES

To study the frequency and intensity of psychotic symptoms in two transversal series of patients with Alzheimer's disease and analyze its relationship with the duration of the disease and severity of cognitive impairment.

PATIENTS AND METHODS

This study has been carried out in patients suffering from probable Alzheimer's disease (NINDS-ADRDA criteria). The stage of the disease was determined according to FAST, and the intensity of cognitive impairment in Mini Mental State Examination was classified as mild, moderate or severe. Frequency and intensity of psychotic symptoms (delusions, hallucinations and misidentifications) were determined by means of semistructured interviews (BEHAVE-AD 78 patients and CUSPAD 69 patients). The results obtained in these three groups of patients were compared through ANOVA variance analysis and mean contrast. Variance and covariance analysis were done to determine the relationship between psychotic symptoms and other variables (degree of cognitive impairment, length of evolution and stage of the disease). For this purpose, the patients with Alzheimer's disease but without psychotic symptoms were considered as control and compared to patients with psychotic symptoms.

RESULTS

Nearly half the patients had psychotic symptoms. Delusions appeared earlier and were more frequent than hallucinations and misinterpretations. The more severe was the cognitive impairment, the more frequent and intense were psychotic symptoms, but the difference was significant only in cases with severe cognitive impairment. Hallucinations appeared mainly in patients with advanced dementia and were related firstly with the intensity of functional and cognitive impairment and secondly with the duration of the disease.

CONCLUSIONS

Mild psychotic symptoms, especially delusions, appear early during the course of Alzheimer's disease. The frequency and intensity of these symptoms increase in parallel with the functional and cognitive impairments caused by the disease. Hallucinations, which appear mainly when the dementia is severe, can be considered as an evolutive marker of the process. Psychotic symptoms differ from those occurring in other disorders, either neurologic or psychiatric in nature.

[Sphenoid metastasis mimicking a meningioma as the initial feature of adenocarcinoma of the prostate]

INTRODUCTION

Presentation of adenocarcinoma of the prostate as an intracranial metastasis is uncommon. This metastasis tends to be seen in the sphenoid bone, and in this case it is difficult to differentiate radiologically from a meningioma. Because this cancer is treatable, the differential diagnosis must be resolved as soon as possible.

CLINICAL CASE

A 72 year old man presented with a rapidly progressive left parasellar syndrome. On neuroimaging there was a tumour at the level of the left lesser wing of the sphenoid, which was isodense and iso-intense and also showed homogeneous uptake of contrast material. On angiography the circulation was pathological with homogeneous delayed filling. The initial diagnosis was meningioma of the lesser wing of the sphenoid. Months later the patient complained of bone and respiratory problems. At this time plain chest X-ray was compatible with carcinomatous lymphangitis. Therefore, tumour markers were studied and for the first time the specific prostatic antigen was investigated and found to be raised. Although there were no symptoms of prostatism, per rectum there was a malignant prostatic mass. In spite of complete hormone block, his illness followed an unfavorable course. At necropsy there was adenocarcinoma of the papillary prostate and a metastasis in the left lesser wing of the sphenoid.

CONCLUSIONS

In elderly men, detection of a sphenoid tumour, which radiologically may appear to be a meningioma and although prostatism has not been diagnosed, the possibility of prostatic metastasis should be considered. Per rectum examination and specific prostatic antigen determination should be done in these patients.

[Verbal fluency and Alzheimer's disease]

BASIC: The loss of verbal fluency in Alzheimer's disease (AD) has been related to the cognitive and functional impairment caused by the disorder.

GOALS

To determine the value of the different types of verbal fluency examination for the detection of AD.

MATERIAL AND METHODS

We have compared the results obtained in the study of verbal fluency in 74 patients with probable AD (NINCDS-ARDRA criteria) to a control group of 64 persons of similar age, gender and educational level. Patients were divided in three categories according to the intensity of dementia: very mild (MMSE > 23), mild (MMSE 18-23) and moderate (MMSE 10-17). Semantic and literal verbal fluencies were studied by means of the "set-test", including in the analysis the results in every of four categories and total, the time consumed per category and the sum of all, the number of animal's names and words given in a minute. We also determined the number of animals in every fifteen seconds up to one minute in 66 controls y 97 patients. Results in the different groups were compared using the ANOVA variance and the contrast of means for alpha < or = 0.05.

CONCLUSIONS

The time consumed in saying the names has a great value in detecting AD, with the same or even better significance than the number of words. It is feasible to shorten the examination and use only one category of names. Our results suggest that counting the names of animals given in the first fifteen seconds does not lower the value of the exam and can also suppress a "roof effect" of the test. A short version of semantic verbal fluency examination could be of potential use in general practice where time consuming exams are difficult to implement.

[Recurrent spontaneous carotid dissection]

INTRODUCTION

Arterial dissection is the cause of 20% of the stroke occurring in adults under the age of 45. The existence of recurrence has been discussed in recent studies, and the overall frequency estimated as 4% to 8%, with a risk of 1% per year. The course of the condition is usually oligosymptomatic, so that a high index of suspicion is necessary for diagnosis to be made. We consider that different connective tissue disorders and anomalies of the vascular wall predispose to dissection. It would seen reasonable to think that these same anomalies may lead to recurrence. However, this cannot always be demonstrated. A family history of dissection is also an important factor in recurrence.

CLINICAL CASES

We present two cases of recurrent spontaneous dissection of the carotid artery from a series of 22 patients with dissection, during the period 1990-1997. In the first case, the second dissection occurred 15 days after the first and in the second case, seven months later. In both cases the recurrence was in the contra-lateral carotid artery. In the second case the vascular tree was noted to have been formed of ecstatic, tortuous vessels.

CONCLUSIONS

Our series shows results similar to others published. In one of these, an underlying arteriopathy which predisposed to the condition was shown. Both followed satisfactory courses. In case 2 a high index of clinical suspicion was necessary, since the recurrence presented as headache alone.

[Dissection of the internal carotid artery with subarachnoid hemorrhage]

INTRODUCTION

Dissection of the intracranial arteries is uncommon, forming less than 10% of all cranio-cervical dissections. Apart from the classical clinical findings of extracranial dissections, intracranial dissection may cause subarachnoid haemorrhage (SAH), mainly dissections involving the posterior circulation.

CLINICAL CASE

We describe the case of a 49 year old man, a smoker, who had a sudden onset of headache followed by loss of consciousness. On CT there was SAH and multiple cerebral infarcts. Arteriography showed findings compatible with dissection of the extracranial and intracranial carotid arteries.

DISCUSSION

We discuss the epidemiology and mechanisms of SAH associated with intracranial dissections. Intracranial dissection. Intracranial dissection should be considered in the differential diagnosis of SAH and of ischaemic syndromes.

[Devic's optic neuromyelitis. Follow-up of the evolution of the medullary lesions using magnetic resonance]

The nosology of Devic's optic neuromyelitis (NMOD) is controversial. Although classically considered to be a variety of multiple sclerosis, there are a number of differentiating characteristics which would permit classification as a separate condition. The evolution of changes in the medulla, as shown by magnetic resonance, is described in a patient with recurrent episodes of myelitis and optic neuritis. In successive exacerbations widening of the medulla was seen, with the appearance of areas of cavitation which later gave rise to atrophy of the medulla. During an 18 year follow-up period the symptoms were only of visual and medullary pathology, on magnetic resonance no other lesions were found in other parts of the central nervous system. The condition corresponded to Devic's optic neuromyelitis (NMOD). Whether it is a variant type of multiple sclerosis or a distinct entity, NMOD shows differentiating characteristics.

Morvan's fibrillary chorea: remission after plasmapheresis

We evaluated the effects of plasmapheresis in two patients with Morvan's fibrillary chorea, one of whom had sigmoid carcinoma, with oligoclonal bands in the cerebrospinal fluid, and modifications of the lipid-oxidative muscle pattern. The use of plasmapheresis in the treatment of Morvan's fibrillary chorea has not been reported previously and in our patients improved the symptoms markedly.

[Plus-minus eyelid syndrome of vascular origin]

The association of unilateral ptosis and contralateral palpebral retraction named as "palpebral plus-minus syndrome" by Gaynard et al is an infrequent finding. Most cases described are of peripheral origin and secondary to muscle pathology or neuromuscular union. Cases secondary to central lesions are exceptional. We present the case of a female patient who developed palpebral plus-minus syndrome as a result of a vascular lesion with presumably mesencephalic localization.

[Multiple entrapments neuropathy in adult polyglucosan body disease]

Adult polyglucosan body disease (APBD) is a rare condition characterized by neuropathy, dementia, upper motor neuron dysfunction and neurogenic bladder. For diagnosis, the presence of polyglucosan bodies (PB), or PAS (+) glucose polymers, must be demonstrated. In this description of a woman with APBD and multiple entrapment neuropathy, we discuss a possible role for morphological changes induced by PB in increasing susceptibility to pressure palsies.

[Complete recovery from transient coma in bilateral paramedian thalamic infarctions]

Bilateral paramedian thalamic infarcts (BPTI) can begin clinically with transient coma, after which symptoms of fluctuating hypersomnolence, irrational behaviour, or amnesic states may be observed. We present two patients with BPTI who began with coma, recovering spontaneously in under eight hours, with no accompanying symptoms.

[Multifocal demyelinating neuropathy with persistent conduction blocks and continuous muscular activity]

A patient developed an initially asymmetric sensory-motor neuropathy, with definite predominance in upper limbs. The examination also disclosed a markedly impaired muscle relaxation. The neurophysiological study showed conduction blocks with continuous muscle activity consisting of myokymias fasciculations and muscle cramps which disappeared after the anesthetic block of the distal nerve segments. In the sural nerve biopsy significant abnormalities were not found. After prednisone and carbamazepine therapy in usual doses the symptoms reverted and the conduction blocks persisted. Neuropathy with persistent conduction blocks is an uncommon disease which exceptionally results in a clinically apparent syndrome of continuous muscle activity. Its recognition is important, as symptoms can disappear after correct therapy.

[The state of muscle cramp disease]

A 65-year-old man presented with daily, almost continuous muscle cramps and painless muscle contractions eight years after being diagnosed as having rheumatoid arthritis. Both cramps and contractions were present at rest, were accentuated by stress and disappeared during sleep. By night-fall the patient was plunged into an extremely disabling condition due to the continuous cramps present in the orofacial, trunk, neck and limb musculature. He even had difficulty speaking. EMG studies demonstrated that both cramps and painless contractions appeared synchronously in muscles innervated by different peripheral nerves. A state of central hyperexcitability is the probable cause of this clinical picture which has remained unchanged over the last six years.