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“Psychometric” Assessment During Transient global Amnesia
NOTE
"PSYCHOMETRIC" ASSESSMENT DURING TRANSIENT GLOBAL AMNESIA Ivan MacG. Donaldson (Department of Medicine, Christchurch Clinical School, and Department of Neurology, Christchurch Hospital, Christchurch, New Zealand)
INTRODUCTION
In Fisher and Adams (1964) initial delineation of the syndrome of transient global amnesia (TGA) 2 of the 17 patients were examined during the attack, although in one it was passing off and the other was atypically prolonged lasting 6 days. Although there are now many papers on TGA in the literature, these have mainly concentrated on aetiology and prognosis. Opportunity for detailed psychometric assessment during attacks seldom presents. Out of 31 cases reviewed by Heathfield et al. (1973) none were actually examined by a neurologist or psychologist during the event. When patients have been tested during the amnesia the examination has usually concentrated on recall of distant or close past events and physical features, with only scant attention paid to other psychological functions. Much hypothesising on the type of neuropsychological disturbance is based on witnesses descriptions. The following case provided an opportunity to assess aspects of psychometric function in TGA. CASE REPORT
A medical practitioner of 63 years of age had spent the day consulting in his office and had driven home in the evening. On arrival he behaved normally, changing his clothes as guests were expected for dinner. When the arrived he seemed perplexed and asked them why they had come. He was unable to recall that they had been invited, although he had discussed this with his wife earlier in the evening and had decanted special wine for the occasion. When examined one and half hours after the onset of the attack he was alert and cooperative. He seemed puzzled and kept asking why the neurologist, whom he recognised, was there, even though this was explained to him on many occasions. He could not recall that his guests were downstairs and that he had invited them to dinner. He had a vague recollection that he had spent the day at the office but could not remember the days events, driving home or what had occurred earlier in the evening. He recognised his wife, guests and surroundings and knew his name, date of birth and address. He could not recall the name of the mayor of the city but knew the names of other prominent people and showed a good grasp of past and current news items. There was no confabulation. He did not know the Cortex (1985) 21, 149-152
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day of the week, date, month or year. His immediate recall of material seemed normal and he could repeat 6 or 7 digits forwards and reverse 5 digits without difficulty. He was told a list of 4 grocery items with their quantities containing 8 pieces of information. This was repeated with him several times to make certain that he understood what was required. After 2 minutes he could not recall any items, quantities or even that he had been asked to remember anything. His spontaneous fluency was normal and he made no mistakes when asked to name objects. He comprehended spoken word normally and was able to perform quite complex verbal instruction such as "when I put my hand into my pocket, but not before, I want you to put your left thumb over your right eye". He could read normally and obeyed written commands without hesitation. His writing to dictation was prompt, legible, and correct. His visuo-spacial orientation seemed normal. He knew his way about the house and where things were in it. He was able to draw a cube and copied other complex shapes without difficulty. There was no apraxia or right-left disorientation. He knew what objects were and what functions they performed. He could mentally substract double digitis from larger numbers without making mistakes but when mentally multiplyng 12 X 13 he obtained 157 on 3 separate attempts. Other aspects of calculation were normal. A detailed neurological and general medical examination was normal apart from a blood pressure of 180/115 mmHg. During the consultation, which lasted 2 hours, his mental state did not change. Shortly after this he went off to sleep. The following morning he seemed perfectly normal. He was alert and fully orientated. He could remember the events of the previous day up until he left his office to drive home. There was no definite recall from then until he awoke. Repeat mental function testing, as outlined above, was normal. Blood count, ESR and the blood concentrations of glucose, urea, electrolytes and fasting lipids were all normal, as were an electrocardiograph and a skull X-ray. Within 2 days he returned to work and there has been no recurrence over four and half years follow-up.
DISCUSSION
Based largely on witness descriptions of attacks it has been postulated that the major abnormality during TGA is impairment of the hippocampal forniceal system (HFS) with inability to form new long term memories, intact short term memory (i.e., immediate recall) and normal or near normal other pychometric functions (Fisher and Adams, 1964; Fisher, 1982). This has been supported by the 5 previously reported cases of psychometric assessment during amnesic attacks (Patten, 1971; Shuttleworth and Wise, 1973; Gordon and Marin, 1979; Ponsford and Donan, 1980; Caffarra et al., 1981 ). Two of these were, however, somewhat atypical of the "pure TGA syndrome" as described by Fisher (Fisher and Adams, 1964; Fisher, 1982) in that they had neurological signs suggesting damage to brain structures outside the HFS (Patten, 1971; Ponsford and Donan, 1980). The underlying pathology in this type of case may be different from that seen in "pure TGA" and thus the psychometric changes may not be quite the same. A 3rd case was unusual in that the attack seemed to be precipitated by the patient describing symptoms of an earlier episode to a medical meeting (Gordon and Marin, 1979). The cases of Shuttleworth and Wise ( 1973) and Caffarra et al. ( 1981) seemed typical, but although memory was carefully assessed in the former,
Transient global amnesia
151
a wider range of tests to examine other aspects of neuropsychological function was not employed. Thus even amongst the few cases where detailed psychometric testing has been performed during TGA there have been difficulties with interpretation and information is sparse. The present patient's findings support the view that there is a consolidation block (Gordon and Marin, 1979) in the formation of new long term memories during the attack (i.e., events during the episode could not be recalled subsequently) in addition to a defect in retrieval (i.e., events earlier in that day could not be remembered during the episode but could be recalled subsequently). There was a short period of permanent retrograde amnesia for the hour or 2 before the attack commenced (Fisher, 1982) demonstrating that recently formed long term memories are particularly vulnerable to erasure. Other studies have shown that the block in the formation of new long term memories during the attack is indeed "global" and affects olfactory, visual, auditory and somatosensory memories (Shuttleworth and Wise, 1973). Memories of all these sensory modalities seem to be processed together and it is likely that gustatory memory is also affected in an attack, although this has never been tested. The present study confirms how selective. this effect on memory can be and during the episode there was nearly perfect preservation of other psychological functions with good recall of distant memories, no receptive or expressive dysphasia, dyslexia, dysgraphia, dyspraxia, right-left disorientation, constructional apraxia or visual agnosia. Mental calculations were performed well and it is uncertain if the repeated minor mistake that he made with multiplication was definitely abnormal. Unlike Patten's (1971) case "mental reorganisation of material" assessed by reversal of digits was not impaired in the present patient or that of Caffarra et al. ( 1981 ). Patten's case, however, was unlike others, which have been studied in detail, in that marked dyscalculia was present.
ABSTRACT
A patient "psychometrically" assessed during an attack of transient global amnesia showed total inability to form new long term memories but normal immediate recall. There was nearly perfect preservation of other psychological functions with good recall of distant events and no dysphasia, dyslexia, dysgraphia, dyspraxia, right-left disorientation, constructional apraxia or visual agnosia. Calculation was probably also normal. Some of the 5 previously reported patients, who have been similarly studied during attacks of transient global amnesia, showed evidence of damage to the brain beyond the hippocampal forniceal system. The present patient demonstrates the market selectivity of memory disturbance in "pure transient global amnesia".
REFERENCES
G., MAZZUCCHI, A. and PARMA, M. Neuropsychological testing during a transient global amnesic episode and its follow-up. Acta Neurologica Scandinavica, 63: 44-50, 1981. FISHER, M.C., and ADAMS, R.D. Transient global amnesia. Acta Neurologica Scandinavica, 40 (Suppl. 9): 25-28, 32-35, 40-42, 1964.
CAFFARRA, P., MORETII,
152
Ivan MacG. Donaldson
FISHER, M.C. Transient global amnesia. Precipitating activities and other observations. Archives of Neurology, 39: 605-608, 1982. GORDON, B., and MARIN, O.S.M. Transient global amnesia: An extensive case report. Journal of Neurology, Neurosurgery and Psychiatry, 42: 572-575, 1979. HEATHFIELD, K.W.G., CROFT, P.B., and SWASH, M. The Syndrome of Transient Global Amnesia. Brain, 96: 729-736, 1973. PATTEN, B.M. Transient Global Amnesia Syndrome. Journal of the American Medical Association, 217: 690-691, 1971. PoNSFORD, J.L., and DONAN, G.A. Transient global amnesia- A hippocampal phenomenon? Journal of Neurology, Neurosurgery and Psychiatry, 43: 285-287, 1980. SHUTTLEWORTH, E.C., and WISE, G.R. Transient Global Amnesia Due to Arterial Embolism. Archives of Neurology, 29: 340-342, 1973. Ivan MacG. Donaldson, Department of Neurology, Christchurch Hospital, Christchurch, New Zeland
"PSYCHOMETRIC" ASSESSMENT DURING TRANSIENT GLOBAL AMNESIA Ivan MacG. Donaldson (Department of Medicine, Christchurch Clinical School, and Department of Neurology, Christchurch Hospital, Christchurch, New Zealand)
INTRODUCTION
In Fisher and Adams (1964) initial delineation of the syndrome of transient global amnesia (TGA) 2 of the 17 patients were examined during the attack, although in one it was passing off and the other was atypically prolonged lasting 6 days. Although there are now many papers on TGA in the literature, these have mainly concentrated on aetiology and prognosis. Opportunity for detailed psychometric assessment during attacks seldom presents. Out of 31 cases reviewed by Heathfield et al. (1973) none were actually examined by a neurologist or psychologist during the event. When patients have been tested during the amnesia the examination has usually concentrated on recall of distant or close past events and physical features, with only scant attention paid to other psychological functions. Much hypothesising on the type of neuropsychological disturbance is based on witnesses descriptions. The following case provided an opportunity to assess aspects of psychometric function in TGA. CASE REPORT
A medical practitioner of 63 years of age had spent the day consulting in his office and had driven home in the evening. On arrival he behaved normally, changing his clothes as guests were expected for dinner. When the arrived he seemed perplexed and asked them why they had come. He was unable to recall that they had been invited, although he had discussed this with his wife earlier in the evening and had decanted special wine for the occasion. When examined one and half hours after the onset of the attack he was alert and cooperative. He seemed puzzled and kept asking why the neurologist, whom he recognised, was there, even though this was explained to him on many occasions. He could not recall that his guests were downstairs and that he had invited them to dinner. He had a vague recollection that he had spent the day at the office but could not remember the days events, driving home or what had occurred earlier in the evening. He recognised his wife, guests and surroundings and knew his name, date of birth and address. He could not recall the name of the mayor of the city but knew the names of other prominent people and showed a good grasp of past and current news items. There was no confabulation. He did not know the Cortex (1985) 21, 149-152
150
Ivan MacG. Donaldson
day of the week, date, month or year. His immediate recall of material seemed normal and he could repeat 6 or 7 digits forwards and reverse 5 digits without difficulty. He was told a list of 4 grocery items with their quantities containing 8 pieces of information. This was repeated with him several times to make certain that he understood what was required. After 2 minutes he could not recall any items, quantities or even that he had been asked to remember anything. His spontaneous fluency was normal and he made no mistakes when asked to name objects. He comprehended spoken word normally and was able to perform quite complex verbal instruction such as "when I put my hand into my pocket, but not before, I want you to put your left thumb over your right eye". He could read normally and obeyed written commands without hesitation. His writing to dictation was prompt, legible, and correct. His visuo-spacial orientation seemed normal. He knew his way about the house and where things were in it. He was able to draw a cube and copied other complex shapes without difficulty. There was no apraxia or right-left disorientation. He knew what objects were and what functions they performed. He could mentally substract double digitis from larger numbers without making mistakes but when mentally multiplyng 12 X 13 he obtained 157 on 3 separate attempts. Other aspects of calculation were normal. A detailed neurological and general medical examination was normal apart from a blood pressure of 180/115 mmHg. During the consultation, which lasted 2 hours, his mental state did not change. Shortly after this he went off to sleep. The following morning he seemed perfectly normal. He was alert and fully orientated. He could remember the events of the previous day up until he left his office to drive home. There was no definite recall from then until he awoke. Repeat mental function testing, as outlined above, was normal. Blood count, ESR and the blood concentrations of glucose, urea, electrolytes and fasting lipids were all normal, as were an electrocardiograph and a skull X-ray. Within 2 days he returned to work and there has been no recurrence over four and half years follow-up.
DISCUSSION
Based largely on witness descriptions of attacks it has been postulated that the major abnormality during TGA is impairment of the hippocampal forniceal system (HFS) with inability to form new long term memories, intact short term memory (i.e., immediate recall) and normal or near normal other pychometric functions (Fisher and Adams, 1964; Fisher, 1982). This has been supported by the 5 previously reported cases of psychometric assessment during amnesic attacks (Patten, 1971; Shuttleworth and Wise, 1973; Gordon and Marin, 1979; Ponsford and Donan, 1980; Caffarra et al., 1981 ). Two of these were, however, somewhat atypical of the "pure TGA syndrome" as described by Fisher (Fisher and Adams, 1964; Fisher, 1982) in that they had neurological signs suggesting damage to brain structures outside the HFS (Patten, 1971; Ponsford and Donan, 1980). The underlying pathology in this type of case may be different from that seen in "pure TGA" and thus the psychometric changes may not be quite the same. A 3rd case was unusual in that the attack seemed to be precipitated by the patient describing symptoms of an earlier episode to a medical meeting (Gordon and Marin, 1979). The cases of Shuttleworth and Wise ( 1973) and Caffarra et al. ( 1981) seemed typical, but although memory was carefully assessed in the former,
Transient global amnesia
151
a wider range of tests to examine other aspects of neuropsychological function was not employed. Thus even amongst the few cases where detailed psychometric testing has been performed during TGA there have been difficulties with interpretation and information is sparse. The present patient's findings support the view that there is a consolidation block (Gordon and Marin, 1979) in the formation of new long term memories during the attack (i.e., events during the episode could not be recalled subsequently) in addition to a defect in retrieval (i.e., events earlier in that day could not be remembered during the episode but could be recalled subsequently). There was a short period of permanent retrograde amnesia for the hour or 2 before the attack commenced (Fisher, 1982) demonstrating that recently formed long term memories are particularly vulnerable to erasure. Other studies have shown that the block in the formation of new long term memories during the attack is indeed "global" and affects olfactory, visual, auditory and somatosensory memories (Shuttleworth and Wise, 1973). Memories of all these sensory modalities seem to be processed together and it is likely that gustatory memory is also affected in an attack, although this has never been tested. The present study confirms how selective. this effect on memory can be and during the episode there was nearly perfect preservation of other psychological functions with good recall of distant memories, no receptive or expressive dysphasia, dyslexia, dysgraphia, dyspraxia, right-left disorientation, constructional apraxia or visual agnosia. Mental calculations were performed well and it is uncertain if the repeated minor mistake that he made with multiplication was definitely abnormal. Unlike Patten's (1971) case "mental reorganisation of material" assessed by reversal of digits was not impaired in the present patient or that of Caffarra et al. ( 1981 ). Patten's case, however, was unlike others, which have been studied in detail, in that marked dyscalculia was present.
ABSTRACT
A patient "psychometrically" assessed during an attack of transient global amnesia showed total inability to form new long term memories but normal immediate recall. There was nearly perfect preservation of other psychological functions with good recall of distant events and no dysphasia, dyslexia, dysgraphia, dyspraxia, right-left disorientation, constructional apraxia or visual agnosia. Calculation was probably also normal. Some of the 5 previously reported patients, who have been similarly studied during attacks of transient global amnesia, showed evidence of damage to the brain beyond the hippocampal forniceal system. The present patient demonstrates the market selectivity of memory disturbance in "pure transient global amnesia".
REFERENCES
G., MAZZUCCHI, A. and PARMA, M. Neuropsychological testing during a transient global amnesic episode and its follow-up. Acta Neurologica Scandinavica, 63: 44-50, 1981. FISHER, M.C., and ADAMS, R.D. Transient global amnesia. Acta Neurologica Scandinavica, 40 (Suppl. 9): 25-28, 32-35, 40-42, 1964.
CAFFARRA, P., MORETII,
152
Ivan MacG. Donaldson
FISHER, M.C. Transient global amnesia. Precipitating activities and other observations. Archives of Neurology, 39: 605-608, 1982. GORDON, B., and MARIN, O.S.M. Transient global amnesia: An extensive case report. Journal of Neurology, Neurosurgery and Psychiatry, 42: 572-575, 1979. HEATHFIELD, K.W.G., CROFT, P.B., and SWASH, M. The Syndrome of Transient Global Amnesia. Brain, 96: 729-736, 1973. PATTEN, B.M. Transient Global Amnesia Syndrome. Journal of the American Medical Association, 217: 690-691, 1971. PoNSFORD, J.L., and DONAN, G.A. Transient global amnesia- A hippocampal phenomenon? Journal of Neurology, Neurosurgery and Psychiatry, 43: 285-287, 1980. SHUTTLEWORTH, E.C., and WISE, G.R. Transient Global Amnesia Due to Arterial Embolism. Archives of Neurology, 29: 340-342, 1973. Ivan MacG. Donaldson, Department of Neurology, Christchurch Hospital, Christchurch, New Zeland