Plasma progranulin levels in cortical dementia phenotypes with asymmetric perisylvian atrophy

BACKGROUND AND PURPOSE

Decreased plasma progranulin levels are a very specific marker for the diagnosis of frontotemporal lobar degeneration (FTLD) caused by mutations in the progranulin gene (GRN). A frequent neuroimaging pattern in this type of dementia is asymmetric cortical atrophy. The aim of this study was to screen for GRN-linked FTLD in cases with different cortical dementia phenotypes and asymmetric perisylvian atrophy.

METHODS

Progranulin plasma levels were analyzed in a variety of FTLD phenotypes (n = 71), dementia of the Alzheimer type (DAT) (n = 22) and probable Lewy body dementia (n = 8), both latter groups presented with asymmetric perisylvian atrophy. A group of elderly controls (n = 29) and DAT cases with symmetric atrophy (n = 33) were also analyzed. The GRN gene was sequenced in cases with lower plasma levels.

RESULTS

Four cases with clinical FTLD phenotypes and plasma levels below 70 ng/ml were found to carry different GRN mutations: M1?, C139R, a point mutation in the splice donor site of intron 3 (A89VfsX41), and a deletion in exon 9 (A303AfsX57), this latter one being a new mutation. Thirteen cases with levels between 72 and 85 ng/ml did not show pathogenic changes in the GRN gene. None of the cases with asymmetric atrophy and clinical phenotypes other than FTLD had GRN mutations.

CONCLUSIONS

Asymmetric perisylvian atrophy is not likely to predict progranulin-linked FTLD unless it is associated with a consistent FTLD clinical phenotype.

[Education provides cognitive reserve in cognitive deterioration and dementia]

INTRODUCTION

The "cognitive reserve" hypothesis states that education provides a better tolerance to brain pathological processes. Consequently, the development of dementia would require more cognitive loss in more educated people. We examine in a cohort of patients with different levels of cognitive impairment, the relationship between the amount of cognitive loss and educational attainment.

METHODS

A total of consecutive outpatients were assessed prospectively with an extensive clinical and neuropsychological protocol, followed up for 6 months, diagnosed by a central expert committee as demented (DSM-III-R criteria) or cognitively impaired. They were included in the Spanish Multicentric Registry of Incident Cases of Dementia. Premorbid verbal fluency (pVF), as a marker of previous cognitive function, was estimated by a validated predictive model. Cognitive loss was defined as the difference between estimated pVF and present observed verbal fluency (oVF) in two ways: as an absolute Z-score (pVF-oVF/sigma of residuals in the normative sample) and as a relative quotient-score (pVF-oVF/pVF).

RESULTS

A two-way ANOVA showed that clinical stage (Z-scores: F=75.88; p<0.0001; quotient-scores: F=126.56; p<0.0001) and also education (Z-scores: F = 83.51; p=0.0001; quotient-scores: F=34.88; p=0.0001) were positively related with both estimates of cognitive loss.

CONCLUSIONS

Our data confirm that education, or some other related factor, determines the amount of cognitive loss needed for clinical expression of the pathological illness and gives the individuals more tolerance to these processes.

Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease

OBJECTIVE

To evaluate the efficacy of a cognitive-motor program in patients with early Alzheimer disease (AD) who are treated with a cholinesterase inhibitor (ChEI).

METHODS

Patients with mild cognitive impairment (MCI) (12), mild AD (48), and moderate AD (24) (Global Deterioration Scale stages 3, 4, and 5) were randomized to receive psychosocial support plus cognitive-motor intervention (experimental group) or psychosocial support alone (control group). Cognitive-motor intervention (CMI) consisted of a 1-year structured program of 103 sessions of cognitive exercises, plus social and psychomotor activities. The primary efficacy measure was the cognitive subscale of the AD Assessment Scale (ADAS-cog). Secondary efficacy measures were the Mini-Mental State Examination, the Functional Activities Questionnaire, and the Geriatric Depression Scale. Evaluations were conducted at 1, 3, 6, and 12 months by blinded evaluators.

RESULTS

Patients in the CMI group maintained cognitive status at month 6, whereas patients in the control group had significantly declined at that time. Cognitive response was higher in the patients with fewer years of formal education. In addition, more patients in the experimental group maintained or improved their affective status at month 12 (experimental group, 75%; control group, 47%; p = 0.017).

CONCLUSIONS

A long-term CMI in ChEI-treated early Alzheimer disease patients produced additional mood and cognitive benefits.

[Neurological complications in a series of 205 orthotopic heart transplant patients]

INTRODUCTION

A heart transplant is the only effective therapeutic option open to many patients with severe heart failure and performing such an intervention is not free of complications. Little is known about the risk factors for neurological complications after a heart transplant.

AIMS

The aim of this study was to identify the risk factors for neurological complications following a heart transplant and, more especially, those associated with epileptic seizures, encephalopathy, cerebrovascular accidents (CVA) and headaches.

PATIENTS AND METHODS

We conducted a retrospective review of the records of 205 orthotopic heart transplant patients and collected clinical, haemodynamic and laboratory data before, during and after the intervention, using a standardised protocol.

RESULTS

95 patients (48%) presented neurological complications. Their frequencies were as follows: encephalopathy (16.6%), epileptic seizures (13.6%), neuromuscular disorders (10.6%), headaches (10.6%), CVA (10.1%), psychiatric disorders (2.2%) and infection of the central nervous system (2.2%). The risk factors for encephalopathy were post-transplant renal failure (RR: 4.6; CI 95%: 1.4-15), post-transplant hepatic failure (RR: 5.6; CI 95%: 1.5-22) and pre-transplant haemodynamic instability (RR: 4.3; CI 95%: 1.3-14); for epileptic seizures they were a cardiac index of < or = 2 L/min/m2 (RR: 23.8; CI 95%: 2-247) and extracorporeal circulation time > or = 115 min (RR: 11.3; CI 95%: 1-79); and for CVA the risk factor was post-transplant hepatic failure (RR: 12.9; CI 95%: 2.5-66).

CONCLUSIONS

Neurological complications often occur after a transplant and are transient. Perioperative haemodynamic instability giving rise to cerebral ischemia and the metabolic disorders secondary to multiple organ failure are determining factors of encephalopathy, epileptic seizures and CVA.

[Non-detected dementia and use of the health services: implications for primary care]

OBJECTIVES

To calculate the proportion of cases of dementia detected in people over 70 living in their homes and to describe the use made by people with dementia of the health and social services.

MATERIAL AND METHODS

Population survey of the survivors of the cohort "Growing old in Leganés", started in 1993. In the third monitoring (1999-2000), the clinical diagnosis of dementia on the basis of a neurological examination and an extensive neuro-psychological battery was included. Their use of health and social services and prior diagnoses were also asked.

RESULTS

In the sample of survivors (n=527), there was 12.1% prevalence of dementia. Only 30% of the demented had previously been diagnosed by the health services. The proportion of undetected dementia was significantly associated with its seriousness (light 95%, moderate 69%, severe 36%). Compared with older persons who were not demented, the demented used more often hospital services, medical and nursing consultations at home and consultations through third parties; and less often, preventive and rehabilitation services. This trend was accentuated in patients with grave dementia. The use of community social services was very low (below 8% in the most serious cases).

CONCLUSIONS

The detection of dementia in the elderly is very low and efforts to detect it in primary care need to be stepped up. Specific social-health resources for this population also need to be increased and the attendance guide-lines for primary care teams, and for health professionals in general, need to be changed.

Visual rating of age-related white matter changes on magnetic resonance imaging: scale comparison, interrater agreement, and correlations with quantitative measurements

BACKGROUND AND PURPOSE

To provide further insight into the MRI assessment of age-related white matter changes (ARWMCs) with visual rating scales, 3 raters with different levels of experience tested the interrater agreement and comparability of 3 widely used rating scales in a cross-sectional and follow-up setting. Furthermore, the correlation between visual ratings and quantitative volumetric measurement was assessed.

METHODS

Three raters from different sites using 3 established rating scales (Manolio, Fazekas and Schmidt, Scheltens) evaluated 74 baseline and follow-up scans from 5 European centers. One investigator also rated baseline scans in a set of 255 participants of the Austrian Stroke Prevention Study (ASPS) and measured the volume of ARWMCs.

RESULTS

The interrater agreement for the baseline investigation was fair to good for all scales (kappa values, 0.59 to 0.78). On the follow-up scans, all 3 raters depicted significant ARWMC progression; however, the direct interrater agreement for this task was poor (kappa, 0.19 to 0.39). Comparison of the interrater reliability between the 3 scales revealed a statistical significant difference between the scale of Manolio and that of Fazekas and Schmidt for the baseline investigation (z value, -2.9676; P=0.003), demonstrating better interrater agreement for the Fazekas and Schmidt scale. The rating results obtained with all 3 scales were highly correlated with each other (Spearman rank correlation, 0.712 to 0.806; P< or =0.01), and there was significant agreement between all 3 visual rating scales and the quantitative volumetric measurement of ARWMC (Kendall W, 0.37, 0.48, and 0.57; P<0.001).

CONCLUSIONS

Our data demonstrate that the 3 rating scales studied reflect the actual volume of ARWMCs well. The 2 scales that provide more detailed information on ARWMCs seemed preferential compared with the 1 that yields more global information. The visual assessment of ARWMC progression remains problematic and may require modifications or extensions of existing rating scales.

Proton magnetic resonance spectroscopy in dementia with Lewy bodies

Proton magnetic resonance spectroscopy ((1)H-MRS) provides a non-invasive, in vivo insight into the brain metabolism, and has been successfully used in several neurological conditions. Our objective was to characterise the cerebral metabolic changes in dementia with Lewy bodies (DLB) patients using (1)H-MRS. Single Voxel (1)H-MRS was performed in 12 DLB patients with mild to moderate symptoms and 11 age-matched healthy controls. Volumes of interest (VOI) were selected, including white matter (WM) in the centrum semiovale and grey matter (GM) in the parasagittal parietal cortex. Main metabolic peaks corresponding to N-acetylaspartate (NAA), glutamate/glutamine (Glx), choline-containing compounds (Cho), myo-inositol (Ins), and creatine plus phosphocreatine (Cr) were identified. These areas were measured and referred to that of the water. Metabolic ratios among the different peak areas were also calculated. In comparison with the control group, DLB patients showed significantly lower mean NAA/Cr, Glx1/Cr and Cho/Cr ratios in the WM, while their Ins/Cr and Ins/NAA ratios did not differ from those of the control group. In the GM, no significant differences were found between both groups. Correlations between age at onset, disease duration, Mini-Mental State Examination, the motor section of the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging and metabolic ratios, both for WM and GM, were not significant in DLB patients. Our spectroscopy data show WM involvement, along with GM preservation, in DLB patients with early or intermediate stages. Hence, (1)H-MRS may provide adjunctive information in the ante-mortem diagnosis of DLB.

[Dementia with Lewy bodies. Pure and mixed forms]

INTRODUCTION AND METHOD

Dementia with Lewy bodies is a generative brain disease of unknown origin, characterised clinically by progressive mental deterioration, with striking fluctuations and transitory episodes of confusion, hallucinations and psychotic symptoms (hallucinations and paranoid deliria), extrapyramidal signs and hypersensitivity to neuroleptic drugs. The main pathological finding was the abundance of Lewy bodies in the neurons of the cortex, brain stem and other subcortical nuclei. In many cases, however, varying amounts of Alzheimer like degenerative lesions are associated.

CONCLUSION

This study analyses the anatomopathological, clinical, diagnostic and therapeutic aspects of this disease.

[Findings using magnetic resonance in a patient with non-traumatic anosmia]

INTRODUCTION

The presence of alterations in the neuroimaging in patients with anosmia without traumatic antecedents is not frequent.

CASE REPORT

Male aged 38 who came to surgery after having suffered, 6 months earlier, for 1 week, a picture of intense, oppressive holocranial headache, accompanied by fever. Associated with this, an acute complete anosmia also began and persisted up to the moment the patient came for consultation. It was not associated with any infection of the respiratory tract, there was no history of cranial trauma, no ingestion of medicines nor toxins, nor had he been exposed to toxic products. The exploration to which he was submitted only showed an anosmia and was otherwise found to be normal. Cranial MRI showed signal alterations in both lower (orbitary) convolutions of the frontal lobes, in the anterior region of the right temporal lobe and in both olfactory nerves. Tests for HIV serology, parotiditis, hepatitis B and C virus, HSV, VZV, Mycoplasma pneumoniae and lues were negative. The acute onset of the anosmia in midst of a picture of febricula and headaches made us suspect the presence of an infectious aetiology, and the alterations found in the neuroimaging could be due to post encephalic lesions, with a special predilection for olfactory areas.

CONCLUSIONS

1. MRI plays a fundamental role in the topographic and aetiological evaluation of olfactory dysfunctions of a central origin; 2. Affectation of the central olfactory passages of an infectious aetiology in a non HIV patient and with neuroimaging findings is a rare complication.

Relationship of angiotensin converting enzyme genotype with serum triglyceride concentration in stroke patients

The Objective of this research was to study the relationship of angiotensin converting enzyme (ACE) genotype with serum triglycerides concentration in stroke patients. The insertion/deletion (I/D) ACE polymorphism was identified by using polymerase chain reaction in 122 prospectively studied ischemic stroke patients (age 45-91 years). Serum triglycerides concentration was determined at admission and 3 months after the stroke, and compared between the ACE genotype groups (37 D/D, 68 D/I, 17 I/I). All clinical characteristics were similar in the three groups. Patients with D/D genotype had mean serum triglycerides concentration significantly higher in acute (179.0+/-111.8 mg/dl) and chronic phase (176.4+/-121.6 mg/dl) than those with I/I genotype (acute phase: 108.7+/-36.1 mg/dl, P=0.019; chronic phase: 116.0+/-44.3 mg/dl, P=0.021). The results showed that serum triglycerides concentration is elevated in stroke patients with the DD ACE genotype and it may be related to the risk of cerebrovascular disease associated with this polymorphism.

White matter changes on CT and MRI: an overview of visual rating scales. European Task Force on Age-Related White Matter Changes

Since the recognition of white matter changes on CT (leukoaraiosis), rating scales for the location and severity of white matter changes have been developed, mainly for research purposes, to investigate factors such as the relation with cognition, risk factors, and pathology. The main purpose of rating scales is to provide scores that can be used in statistical analyses. The development of the NINDS-AIREN criteria for vascular dementia have introduced a new application for these rating scales in investigating and delineating the amount of white matter changes on CT/MRI sufficient to fulfill the criteria. Furthermore, in Alzheimer's disease, recognition of white matter changes may serve to delineate homogeneous groups and help to identify patients with different symptomatology. We reviewed the existing rating scales for CT and MRI and judged their properties and reliability. The ideal rating scale does not yet exist, but different rating scales may serve different purposes, for which some recommendations are made.

[Clinical manifestation of frontotemporal dementia]

Frontotemporal dementia is a degenerative disease, usually of presenile onset, frequently with positive family history, whose main clinical features are early social and personal behavioral disturbances, cognitive defects mainly in attention, language and executive functions, personality disorders and blunt, unconcerned and subdepressive affect. Anatomic and functional neuroimaging shows atrophy and functional defects in anterior brain regions, and the EEG is persistently normal. Although frontotemporal dementia has been confounded with Alzheimer's disease for long time, it can be identified on clinical grounds in order to perform new therapeutic trials.

Nimodipine in subcortical vascular dementia trial

Vascular dementia (VaD) is a heterogeneous pathology currently regarded as the result of a variety of causes. Different types of VaD can be identified according to different criteria. This heterogeneity might be one of the causes of the controversial results observed, up to now, in clinical trials. Recently, the 10th revision of the International Classification of Diseases (ICD-10) explicitly identified subcortical VaD as a well-defined subgroup. Abnormalities of white matter are clearly detectable with computed tomography or magnetic resonance scans. The clinicoradiological association of dementia, blood hypertension, and other vascular risk factors, extensive white matter lesions, and small subcortical infarcts might be considered as a clinical univocal entity. Following the encouraging results of a preliminary pilot study, the above-mentioned criteria were followed to define a population of patients to be enrolled in a double-blind, parallel-groups, placebo-controlled clinical trial with nimodipine, which has been proposed as a drug that can improve cognitive functions in patients with VaD. The paper discusses the protocol design of this ongoing trial and its main entry criteria, with particular emphasis on the definition of the population to be enrolled. Implication for future trials in subcortical VaD are discussed further.

Is subcortical vascular dementia a clinical entity for clinical drug trials?

Several therapeutic trials have been performed for vascular dementia, with drugs differing in type and mechanism of action. The results have been almost invariably inconclusive. Given the current notion that there are different subtypes of vascular dementia according to pathophysiological mechanisms, it is reasonable to suspect that one of the main causes of the disappointing results was that the study samples included patients not fitting with the rationale of selective treatments. Testing this hypothesis is difficult because characterization of patients in relation to different subtypes of vascular dementia is not available for most studies. However, attempts are ongoing to reclassify patients entered in some trials for post hoc subgroup analyses with some preliminary interesting results. We propose that (1) specific subtypes of vascular dementia should be the target in any single trial using a treatment with a proper rationale; and (2) subcortical vascular dementia, caused by small vessel disease leading to lacunar infarcts and subcortical white matter changes, represents a clinically and radiologically well-defined entity to be considered for future trials designed specifically for testing adequate drugs.

Ancestral origins and worldwide distribution of the PRNP 200K mutation causing familial Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) belongs to a group of prion diseases that may be infectious, sporadic, or hereditary. The 200K point mutation in the PRNP gene is the most frequent cause of hereditary CJD, accounting for >70% of families with CJD worldwide. Prevalence of the 200K variant of familial CJD is especially high in Slovakia, Chile, and Italy, and among populations of Libyan and Tunisian Jews. To study ancestral origins of the 200K mutation-associated chromosomes, we selected microsatellite markers flanking the PRNP gene on chromosome 20p12-pter and an intragenic single-nucleotide polymorphism at the PRNP codon 129. Haplotypes were constructed for 62 CJD families originating from 11 world populations. The results show that Libyan, Tunisian, Italian, Chilean, and Spanish families share a major haplotype, suggesting that the 200K mutation may have originated from a single mutational event, perhaps in Spain, and spread to all these populations with Sephardic migrants expelled from Spain in the Middle Ages. Slovakian families and a family of Polish origin show another unique haplotype. The haplotypes in families from Germany, Sicily, Austria, and Japan are different from the Mediterranean or eastern European haplotypes. On the basis of this study, we conclude that founder effect and independent mutational events are responsible for the current geographic distribution of hereditary CJD associated with the 200K mutation.

[A comparison between 2 abbreviated Spanish versions of mental status assessment in the diagnosis of dementia. Study data on elderly community residents]

BACKGROUND

There are several Spanish versions and adaptations of the Mini-Mental State Examination (MMSE), the most used abbreviated test for screening of the cognitive decline in clinical and epidemiological setting. Among them, the Mini-Examen Cognoscitivo (MEC) is highlighted. The aim of this study was to compare the diagnostic usefulness between the Spanish translation of the MMSE (the MMSE1 which incorporates the proof of serial "sevens" and the MMSE2 which includes spelling "world" backward) and the MEC for the diagnosis of dementia.

PATIENTS AND METHODS

A sample of elderly persons (65 years or over), included in a population-based study of dementia prevalence. The diagnosis of dementia was assessed through exhaustive neuropsychological evaluation. The diagnosis of dementia (according to the standardized DSM-III-R criteria) was carried out by expert neurologists, who were independent and blind to the scores obtained in the MMSE and MEC.

RESULTS

79 subjects underwent both tools and neuropsychological assessment. The MMSE1 obtained the highest accuracy (92%), followed by the MEC (90%) and the MMSE2 (83%). The analysis of the areas under receiver operating characteristic curves did not show significant statistical differences between the MMSE1 and MEC (p = 0.38), but significant differences were observed between those and the MMSE2 (p = 0.01).

CONCLUSIONS

The diagnostic usefulness of Spanish translation of the MMSE is similar to the MEC. The proof of spelling "world" backward obtained poorer results than serial "sevens". The Spanish versions of the MMSE should be improved to be adapted to our cultural characteristics.

[Intracranial hypotension and sixth cranial nerve palsy]

The sixth cranial nerves may be involved in rare cases of post-puncture syndrome after lumbar anesthesia as well as in cases of spontaneous intracranial hypotension. We present 3 cases of spontaneous intracranial hypotension with unilateral or bilateral sixth nerve palsy.

[Multicenter register of index cases of dementia. A study by the Spanish Neurological Society's dementia group]

We report the objectives and case registration methods used by neurologists belonging to the Spanish Neurological Society's dementia group (GERMICIDE). Forerunners of the present project are also described. The group's principal aim, which is to determine the distribution of dementia in the "neurological" environment is pursued by enrolling consecutive index cases (new presentations) arriving at 18 Spanish neurological units over a period of 2 years. A standard protocol was used to study the patients and final diagnoses were agreed upon in keeping with international criteria for dementia and the main neurological diseases (DSM-III-R, CDR and others). A second objective is to study risk factors for the main etiological groups of dementia (Alzheimer's disease and vascular dementia) and to follow each patient in the cohort until death in order to assess the course of disease and its biological markers. The series will be large, as there are already over 800 cases listed in the coordinating centre even though the period of enrollment has not ended.

Alcoholic cognitive deterioration and nutritional deficiencies

Chronic alcoholic patients frequently exhibit a mild to moderate cognitive impairment that has been related to Wernicke-Korsakoff encephalopathy and attributed tentatively to nutritional and vitamin deficiencies. To elucidate the possible relation between alcoholic cognitive deterioration (ACD) and nutritional and vitamin deficiencies, several tests of intelligence and memory were administered to 54 chronic alcoholic patients and 30 controls. Serum levels of thiamine, folic acid, vitamins B12, A, and E, and certain nutritional indexes were determined in most of the subjects. The alcoholics scored significantly lower in intellectual and visuospatial tasks but not in verbal memory tasks. They had a lower serum level for thiamine but not of the remaining vitamins. However, the correlations between serum thiamin and cognitive performance scores were low, and according to stepwise regression analysis, duration of alcohol intake and education were the variables with predictive value for intellectual and memory test performance. These results suggest that serum thiamin deficiency is not the main pathogenetic factor related to ACD.

Serum levels of vitamin A in Parkinson's disease

To elucidate a possible role of vitamin A in the pathogenesis of Parkinson's disease (PD) we compared serum levels of retinol (vitamin A), measured by HPLC, and the vitamin A/retinol binding protein (RBP) ratio of 42 PD patients (22 males and 20 females, mean age 67.3 +/- 1.34 years) and their respective spouses as control group (20 males and 22 females, mean age 66.2 +/- 1.42). The serum levels of vitamin A did not differ significantly between the 2 groups (0.59 +/- 0.03 microgram/dl for PD patients and 0.57 +/- 0.03 microgram/dl for controls), nor did the vitamin A/RBP ratio (0.87 +/- 0.04 and 0.82 +/- 0.03, respectively). There was no influence of antiparkinsonian therapy on vitamin A or vitamin A/RBP ratio. Serum levels of vitamin A, and vitamin A/RBP ratio did not correlate with age, age at onset, scores of the Unified Parkinson's Disease Rating Scale or the Hoehn and Yahr staging in the PD group. These results suggest that serum concentrations of vitamin A, do not play a role in the pathogenesis of PD.

[The inefficacy of zidovudine (AZT) in progressive multifocal leukoencephalopathy (PML) associated with the acquired immunodeficiency syndrome (AIDS)]

The clinical case of a patient suffering AIDS who presented a progressive multifocal leukoencephalopathy (PML), diagnosed by CT scan, magnetic resonance imaging (MRI) and cerebral biopsy, is here described. A therapeutic trial was carried out with zidovudine (200 mg/4 hours p.o.) during 75 days. Although this treatment diminished the number of infections, a progression of PML was clinically observed, as well as the appearance of new lesions in the cerebral white matter in the MRI. The inefficacy of zidovudine in PML associated to AIDS is discussed.

[Neuro-psychological disorders in hypothyroid dementia. Description of case]

Hypothyroidism is one of the most frequent causes of treatable symptomatic dementia. However a detailed description of its neuropsychologic characteristics in the medical literature is lacking. We have studied a 70 year old patient suffering severe mental deterioration, cerebellopathy, myopathy and hypothyroidism with a complete set of neuropsychologic and psychometric tests: mental mini-examination, Blessed's scale, neuropsychologic examination, WAIS, Bento visual retention test, Rey's picture, words learning, delayed recall of words, verbal fluency, reaction times and maintained attention. This type of dementia is characterized by a low score in all tests which improves progressively with the treatment and it is also accompanied by a lack of language defects, nonconstructive apraxia or agnosia. The recovery involves the attentional field and the memory as well as the two intelligence indices. However this improvement is more apparent in the tests related to attention and visuospatial information processing. It is concluded that hypothyroid dementia in this patient had characteristics "subcortical dementia" and a neuropsychologic deterioration pattern rather nonspecific with a slight predominance of the attentional and visuospatial defects.

Vascular dementia. A clinicopathological study

We have reviewed the clinical and pathological records of 40 aged patients who showed only vascular lesions on histological examination. They were followed up for 3.5 +/- 6.3 years before death, and in 28 cases the diagnosis of dementia was done during life. Demographic data, vascular and systemic illnesses, psychiatric neurological and neuropsychological disturbances, and pathological findings were compared between demented and non-demented patients. The number of strokes, several neurological and almost all neuropsychological disturbances, the volume of macroscopic cerebral infarct, especially in frontal, occipital and basal regions, the lacunar state and the white matter lesions, were significantly greater in demented patients. However most of them had less than 100 ml3 of brain infarct. The relative influence of each type of cerebral vascular lesion upon the dementia syndrome was determined by means of multivariate analysis. The volume of macroscopic cerebral infarct, the white matter lesion and the lacunar state showed quite similar contributions to mental deterioration.

Risk factors for spontaneous cerebral hematomas. Case-control study

In a case-control study of 73 cases of cerebral hematoma diagnosed by CT scan, significant risk factors were history of hypertension, chronic alcoholism, evidence of hepatic disease, EKG abnormalities and high hematocrit values. Initial blood pressure was significantly higher in cases, but blood pressure on the third day after admission was not different from controls. Hypertension and alcoholism did not show a clear correlation, but data from other studies explain the role of alcoholism in vascular disease through a relation with high blood pressure. Risk factors were similar in lobar and basal ganglia hematomas.

Neurotransmitter changes in cerebrospinal fluid in the Spanish toxic oil syndrome: human clinical findings and experimental results in mice

Patients with Spanish Toxic Oil Syndrome (TOS) complaining of neuromuscular symptoms had increased levels of homovanillic acid and 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid. Severity of pain and muscle cramps correlated with the magnitude of increment in levels of monoamine metabolites. Mice treated with oleyl anilide, a putative toxic compound found in some stocks of the toxic rapeseed oil, did not present clinical or anatomical findings compatible with TOS. However, biochemical studies in these mice revealed a depletion of serotonin and an elevation of 5-HIAA levels. Our findings suggest that the unidentified toxic agent of the TOS and oleyl anilide induce pharmacological changes in monoamine neurons of the brain.