- Email: [email protected]
The aprosodias: Clinical manifestation and significance of the syndrome
Abstracts / Journal of the Neurological Sciences 283 (2009) 240–320
In recent years, a great deal of interest has been generated around the concept of a boundary or transitional state between normal aging, and dementia, or more specifically, vascular dementia (VD) or Alzheimer's disease (AD). This condition has received a number of descriptions including mild cognitive impairment (MCI). Clinical and neurobiological evidence indicates that subjects with MCI are at an increased risk for developing AD or VD. In this retrospective cross-sectional study we quantified brain atrophy, leukoaraiosis and lacunas and blotted the data with age and memory tests. Altogether 297 patients (MMSE 20–25) from both genders were involved in this study from 8 different hospitals. The mean age was 63 years (40–75). Subjects were diagnosed as mild or moderate cognitive impairment (MMSE: average 24.21). Cortical and sub-cortical atrophy were defined by measuring the Sylvian index (> 0.02), and by the bicaudate index (>0.2) (van Zagten et al., 1999). Leukoaraiosis and lacunas were delineated by two radiologists and all the MRI pictures were scanned and digitalized. The total area and number of lacunas, the total area of leukoaraiosis were measured on the consecutive brain slices. Indexes of cortical and sub-cortical atrophy were also included in the clustering procedure. In memory tests the reaction time (RT) was measured, accuracy (ACC) and sensitivity index (SI) were also calculated. Clusters (mild, moderate and sever subgroups) were produced by the Self Organizing Map (SOM) method (Kohonen, 1985), which could be used for clustering data without knowing the original class memberships of the input. Cluster analysis is used to identify and group respondents that are similar. If any outlier values were identified by the outlier analysis they could be removed from the evaluation. Canonical correlation was used to study the inter-correlational structure, an additional procedure for assessing the relationship between variables. Analysis of brain morphology documented a strong correlation between sub-cortical atrophy and areas of leukoaraiosis and/or lacunas. The extension of leukoaraiosis correlated to the total areas of lacunas. Finally, in the age groups older than 66, the area of leukoaraiosis and lacunas is age-dependent. On the basis of vascular pathology calculated by the SOM method the 4 groups were as follows: severe, moderate, mild groups and group without pathology. The average age of the 4 groups was significantly different (67, 65, 61 and 59) similarly to the MMSE values (23.94, 24.04, 24.34, 24.54) and the averaged reaction times in ms (983.69, 957–33, 960.96, 830.57). In groups of patients with or without atrophy, we found that memory decline accelerated above 65 in both groups, while the age dependent increase of leukoaraiosis or lacunas was consequently higher in the atrophy group. We can conclude that in our cohort of patients with MCI, the age related increase of total area of WMH, or lacunas is significant. Leukoaraiosis and lacunas have a high correlation (correlation factor 0.59, p > 0.001). Both pathologies can be the consequence of hypertension. The absolute increase of WMH was 1.1 cm3 over an observation period of 4 years in the elderly population (Schmidt et al., 2002) while in our cohort, in different age groups, the calculated differences for 4 years of aging were 0.26 cm3 in no-atrophy group and 0.742 cm3 in group with atrophy. Age related worsening was also found in computerized memory tests. No significant relationship between vascular risk factors and MCI could be found.
viously taken by the patients were withdrawn 2 weeks before the beginning of the examination. The data of CV pts. were compared with 25 age-matched persons waiting for coronary bypass, without any neurological symptoms, carotid stenosis or silent brain infarct (confirmed by imaging). The following tests were performed. Word listing measures the verbal short-term memory: 4.64 + 1.96 in CV pts. and showed significantly worse result compared with controls. Digit Symbol Test detects the psychomotor performance, motor persistence, sustained attention, response speed and visuo-motor coordination 23.4 + 11.8 in CV group without significant differences to controls. Trail-Making examines the speed of cognitive performance and processing, and visual, conceptual and visuo-motor tracking. 67.6 + 39.8 in CV group, worse performance than in controls. Digit Span forward and backward measures immediate verbal memory, attention and concentration. The sum (forward + backward) was 9.3 + 1.4 in CV group, similar values than those of controls. Conclusion: The cognitive tests did not reflect the severity of ischemic deficits. doi:10.1016/j.jns.2009.02.145
Evidence based treatment of dementia: What can we learn from the Cochrane library? D. Bereczkia,b a Department of Neurology, Semmelweis University, Budapest, Hungary b Department of Neurology, University of Debrecen, Debrecen, Hungary Background: Systematic reviews of health care interventions in a single database have great practical value. Methods: We analyze the dementia related information in the Cochrane Library. Results: In 2007 the Cochrane Library has close to 5000 systematic reviews, and in the latest—2007/3—issue 98 reviews which include the term dementia in their title, abstract or keywords. The Cochrane Dementia and Cognitive Improvement Group has a major role in preparing systematic reviews of randomized clinical trials in the field of dementia. Pharmacological as well as non-pharmacological interventions are analyzed. The reviews have strictly organized structure. Cochrane reviews or at least their abstracts are available free of charge at www.cochrane.org Based on the results of these systematic reviews, an intervention may be evaluated as follows: • • • •
Acknowledgement I would like to thank the participating centers for the good quality of data, the morphometric and mathematical analysis is Imre E?rd?gh work. doi:10.1016/j.jns.2009.02.144
Our experiences with cognitive testing in ischemic and CABG patients a
a
277
Evidence of effect: the clinical trials proved beneficial treatment effect. Evidence of harm: trials proved that the intervention is harmful. Evidence of no effect: trials proved that the intervention has neither harm nor benefit. Not enough evidence of effect: there is not enough information; studies are not conclusive (the intervention can be harmful, beneficial or neutral), therefore further research is needed.
In addition to systematic reviews, the Cochrane Library includes a large database of bibliographic data of randomized controlled trials, technology assessments and economic evaluations. Conclusions: The use of this source of information is strongly recommended for all who are involved in patient care or health care policy. doi:10.1016/j.jns.2009.02.146
b
L. Csiba , S. Molnár , V. Kemény Neurology, Debrecen University, Debrecen, Hungary Gedeon Richter Co., Budapest, Hungary Background: To compare the results of cognitive testing of multiinfarct pts. with that of coronary pts. Methods and results: The study was performed on 50 persons. 25 righthanded, multifocal cerebral infarct pts. (mean age + SD: 63.4 + 9.39) were investigated, whose diagnosis was confirmed by MRI. Patients with serious residual stroke symptoms (aphasia, severe hemiparesis) were excluded (Rankin-scale > 3, MMSE 26.8 ± 1.5 mean ± SD). All nootropic drugs pre-
The aprosodias: Clinical manifestation and significance of the syndrome P. Tariska Memory Clinic, National Institute of Psychiatry and Neurology, Budapest, Hungary Prosody consists of different variations in sound pitch, stress and rhythm underlying speech melody and inflection [1]. The prosodic components of speech assist in inferring the attitude and emotion of the speaker and are
278
Abstracts / Journal of the Neurological Sciences 283 (2009) 240–320
vital in everyday communication. A review of the literature suggests that the left hemisphere is responsible for modulating the linguistic components of prosody (e.g., timing), whereas the right hemisphere is predominantly responsible for modulating the affective components of prosody (e.g., spectral information or pitch). Aprosodia, the inability to either produce or comprehend the affective components of speech or gesture, is a common occurrence after brain injury. The two basic forms are: executive and receptive ones. (2). Both forms are extremely important in the communication abilities of the patient. Receptive dysprosodia separates the patients from the emotions of others; motoric dysprosodia impairs the ability to adequately communicate. Disorders of affective aprosodia have been classified along the same dimensions as the aphasias. Bedside evaluation and neuroimaging have been used to identify and classify types of aprosodia. The treatment goals for aphasia may be adapted and applied to aprosodia. Additionally, pharma-cotherapy and biofeedback have been found useful in the treatment of aprosodia and associated features. Neuroanatomical basis of dysprosodias is widespread: several brain regions are involved (executive forms: frontal, hemisphere lesions, basal ganglia dysfunction, ce-rebellar lesion etc; receptive forms: right temporoparietal regions). Especially right temporo-parietal lesion can cause both forms of dysprosodias (3). Recent study highlighted the frequency of aprosody in patients suffering from Alzheimer's disease opposed to patients with vascular dementia (4). Short case history of 8 patients of the Memory Clinic is briefly presented having dysprosody of non-aphasic origin. Their observation underlays the heterogenic origin of the symptom that can be present in the frame of dementia disease, mild cognitive impairment of unknown origin, diseases of basal ganglia and furthermore mixed or pure psychogenic origin as well. References [1] Monrad-Crohn GH. Dysprosody or altered “melody of language”. Brain 70: 405–415, 1947.
doi:10.1016/j.jns.2009.02.147
Carotid stenosis and cognitive function
Detection of cerebral microbleeds in patients treated with oral anticoagulants
H. Werschinga, C. Stehlingb, S. Kloskab, L. Eckardtc, W. Heindelb, S. Knechta a Department of Neurology, University of Muenster, Muenster, Germany b Department of Clinical Radiology, University of Muenster, Muenster, Germany c Department of Cardiology and Angiology, University of Muenster, Muenster, Germany Background and aims: Cerebral microbleeds (CMBs) are perivascular hemosiderin deposits frequently detected in patients with intracerebral hemorrhage and ischemic cerebral infarction. If proven a marker for bleedingprone microangiopathy, CMBs might be of prognostic value in the therapeutic decision of anticoagulation. The purpose of our study was to evaluate the appearance of CMBs using Gradient echo T2⁎-weighted MRI in persons treated with oral anticoagulants without symptomatic cerebrovascular disease. Methods: We used the data of 494 elderly individuals (mean age 62 years, 247 male), who took part in an interdisciplinary population-based cohort study of healthy aging (SEARCH-Health). All subjects underwent clinical examination, neuropsychological testing and 3.0 T MRI. CMBs were defined as focal areas of low signal intensity on T2⁎MRI of less than 10 mm in diameter. White matter hyperintensities were calculated semiquantitatively. Results: Forty-nine individuals currently used oral anticoagulants. CMBs were found in 10 of 49 individuals with anticoagulation, and in 38 of 407 individuals without anticoagulation (p < .05); however, beside treatment with anticoagulants, advanced age and the presence of cardiovascular disease (arterial hypertension, arterial fibrillation, ischemic heart disease) was significantly more common in subjects with CMBs than in those without. Adjusting for these factors in logistic regression analysis showed that only arterial hypertension and ischemic heart disease were considered to be significant and independent predictors of CMBs. Furthermore subjects with CMBs had significantly more white matter intensities. Conclusions: In our study CMB prevalence is more than two times higher among patients with anticoagulative treatment compared to those without such a therapy. But it seems to be rather an effect of associated cardiovascular risk factors than a consequence of the anticoagulatory effect itself. This finding is supported by the fact, that the manifestation of CMBs in our study is highly correlated with the degree of white matter disease.
L.K. Sztriha Department of Neurology, University of Szeged, Szeged, Hungary
doi:10.1016/j.jns.2009.02.149
While stroke is a known cause of cognitive impairment, the relationship between carotid artery stenosis and cognitive function in people without a history of stroke is less clear. A number of risk factors for vascular disease are related to cognitive impairment. Hypertension, diabetes mellitus, cigarette smoking, and dyslipidemia are associated with an increased risk of carotid artery disease too. Some studies have suggested that stenosis of the internal carotid artery may be an independent risk factor for cognitive impairment. Cognitive impairment and decline tend to be more frequent with left-sided stenosis, if tests for dominant hemispheric function in right-handed individuals are utilized during the assessment. The possible pathomechanisms of cognitive impairment include silent embolization and hypoperfusion. High-grade stenosis of the internal carotid artery may be associated with cognitive impairment even without evidence of infarction on magnetic resonance imaging. On the other hand, it is fairly common that patients have normal cognition despite severe carotid artery disease, highlighting the important role of an efficient collateral blood supply. The carotid intimamedia thickness appears to be a marker of underlying risk factors and generalized atherosclerosis, rather than a direct cause of cognitive impairment. Carotid endarterectomy or stenting may lead to a decline in cognitive function due to microembolic ischemia or intraprocedural hypoperfusion. Conversely, restoring perfusion could improve cognitive dysfunction that might have occurred from a state of chronic hypoperfusion. It is unclear whether these complex interactions ultimately result in a net improvement or a deterioration of cognitive function. Evidence at present does not seem strong enough to include loss of cognition as a factor in determining the balance of risk and benefit from therapy for asymptomatic carotid stenosis.
Severe visuo-spatial impairment following a right occipital ischemic stroke: A new form of single strategic infarct dementia?
doi:10.1016/j.jns.2009.02.148
M. Marianetti, C. Mina, F. Micacchi, P. Marchione, P. Giacomini Department of Neurology and ORL/University of Rome, Rome, Italy Background and aims: Single Strategic Infarct Dementia is reported as a possible consequence of large strokes of anterior/lateral/subcortical cerebral areas having a key role for cognitive functioning (usually left/right angular gyrus, temporal lobes, frontal lobes, thalamus, caudatus, genu of left internal capsula). A correct neuropsychological classification of the disease is still lacking. Methods and results: We present the case of a 67-year-old, right handed woman, affected by hypertension and dyslipidemia, who two years before our observation started to suffer from cognitive impairment after a large right occipital ischemic stroke. Neurologically she presented a left homonymous hemianopsia and an evident visuospatial disturbance for which we administered her this neuropsychological test battery: Mini Mental State Examination, Rey's 15 Words Test (immediate and delayed recall), Rey's Complex Figure (copy, immediate recall and delayed recall), Attentive Matrices, Raven's Progressive Matrices, Frontal Assessment Battery, Phonological and Semantic Verbal Fluency Test, Trail Making Test A/B, Ideomotor and Orofacial Apraxia Test, Judgment of Line Orientation Test (JLOT), Street Completion Test, Recognition of Unknown Faces Test, Elaboration of Colors, Recognition of Facial Expressions, Recognition of Famous Faces and Famous Places, Clock Drawing Test, Line Bisection Test, Token Test, Boston Naming Test, Clinical Dementia Rating Scale(CDR). This battery revealed absence of neglect, a mild compromission of memory, attention and executive functions
In recent years, a great deal of interest has been generated around the concept of a boundary or transitional state between normal aging, and dementia, or more specifically, vascular dementia (VD) or Alzheimer's disease (AD). This condition has received a number of descriptions including mild cognitive impairment (MCI). Clinical and neurobiological evidence indicates that subjects with MCI are at an increased risk for developing AD or VD. In this retrospective cross-sectional study we quantified brain atrophy, leukoaraiosis and lacunas and blotted the data with age and memory tests. Altogether 297 patients (MMSE 20–25) from both genders were involved in this study from 8 different hospitals. The mean age was 63 years (40–75). Subjects were diagnosed as mild or moderate cognitive impairment (MMSE: average 24.21). Cortical and sub-cortical atrophy were defined by measuring the Sylvian index (> 0.02), and by the bicaudate index (>0.2) (van Zagten et al., 1999). Leukoaraiosis and lacunas were delineated by two radiologists and all the MRI pictures were scanned and digitalized. The total area and number of lacunas, the total area of leukoaraiosis were measured on the consecutive brain slices. Indexes of cortical and sub-cortical atrophy were also included in the clustering procedure. In memory tests the reaction time (RT) was measured, accuracy (ACC) and sensitivity index (SI) were also calculated. Clusters (mild, moderate and sever subgroups) were produced by the Self Organizing Map (SOM) method (Kohonen, 1985), which could be used for clustering data without knowing the original class memberships of the input. Cluster analysis is used to identify and group respondents that are similar. If any outlier values were identified by the outlier analysis they could be removed from the evaluation. Canonical correlation was used to study the inter-correlational structure, an additional procedure for assessing the relationship between variables. Analysis of brain morphology documented a strong correlation between sub-cortical atrophy and areas of leukoaraiosis and/or lacunas. The extension of leukoaraiosis correlated to the total areas of lacunas. Finally, in the age groups older than 66, the area of leukoaraiosis and lacunas is age-dependent. On the basis of vascular pathology calculated by the SOM method the 4 groups were as follows: severe, moderate, mild groups and group without pathology. The average age of the 4 groups was significantly different (67, 65, 61 and 59) similarly to the MMSE values (23.94, 24.04, 24.34, 24.54) and the averaged reaction times in ms (983.69, 957–33, 960.96, 830.57). In groups of patients with or without atrophy, we found that memory decline accelerated above 65 in both groups, while the age dependent increase of leukoaraiosis or lacunas was consequently higher in the atrophy group. We can conclude that in our cohort of patients with MCI, the age related increase of total area of WMH, or lacunas is significant. Leukoaraiosis and lacunas have a high correlation (correlation factor 0.59, p > 0.001). Both pathologies can be the consequence of hypertension. The absolute increase of WMH was 1.1 cm3 over an observation period of 4 years in the elderly population (Schmidt et al., 2002) while in our cohort, in different age groups, the calculated differences for 4 years of aging were 0.26 cm3 in no-atrophy group and 0.742 cm3 in group with atrophy. Age related worsening was also found in computerized memory tests. No significant relationship between vascular risk factors and MCI could be found.
viously taken by the patients were withdrawn 2 weeks before the beginning of the examination. The data of CV pts. were compared with 25 age-matched persons waiting for coronary bypass, without any neurological symptoms, carotid stenosis or silent brain infarct (confirmed by imaging). The following tests were performed. Word listing measures the verbal short-term memory: 4.64 + 1.96 in CV pts. and showed significantly worse result compared with controls. Digit Symbol Test detects the psychomotor performance, motor persistence, sustained attention, response speed and visuo-motor coordination 23.4 + 11.8 in CV group without significant differences to controls. Trail-Making examines the speed of cognitive performance and processing, and visual, conceptual and visuo-motor tracking. 67.6 + 39.8 in CV group, worse performance than in controls. Digit Span forward and backward measures immediate verbal memory, attention and concentration. The sum (forward + backward) was 9.3 + 1.4 in CV group, similar values than those of controls. Conclusion: The cognitive tests did not reflect the severity of ischemic deficits. doi:10.1016/j.jns.2009.02.145
Evidence based treatment of dementia: What can we learn from the Cochrane library? D. Bereczkia,b a Department of Neurology, Semmelweis University, Budapest, Hungary b Department of Neurology, University of Debrecen, Debrecen, Hungary Background: Systematic reviews of health care interventions in a single database have great practical value. Methods: We analyze the dementia related information in the Cochrane Library. Results: In 2007 the Cochrane Library has close to 5000 systematic reviews, and in the latest—2007/3—issue 98 reviews which include the term dementia in their title, abstract or keywords. The Cochrane Dementia and Cognitive Improvement Group has a major role in preparing systematic reviews of randomized clinical trials in the field of dementia. Pharmacological as well as non-pharmacological interventions are analyzed. The reviews have strictly organized structure. Cochrane reviews or at least their abstracts are available free of charge at www.cochrane.org Based on the results of these systematic reviews, an intervention may be evaluated as follows: • • • •
Acknowledgement I would like to thank the participating centers for the good quality of data, the morphometric and mathematical analysis is Imre E?rd?gh work. doi:10.1016/j.jns.2009.02.144
Our experiences with cognitive testing in ischemic and CABG patients a
a
277
Evidence of effect: the clinical trials proved beneficial treatment effect. Evidence of harm: trials proved that the intervention is harmful. Evidence of no effect: trials proved that the intervention has neither harm nor benefit. Not enough evidence of effect: there is not enough information; studies are not conclusive (the intervention can be harmful, beneficial or neutral), therefore further research is needed.
In addition to systematic reviews, the Cochrane Library includes a large database of bibliographic data of randomized controlled trials, technology assessments and economic evaluations. Conclusions: The use of this source of information is strongly recommended for all who are involved in patient care or health care policy. doi:10.1016/j.jns.2009.02.146
b
L. Csiba , S. Molnár , V. Kemény Neurology, Debrecen University, Debrecen, Hungary Gedeon Richter Co., Budapest, Hungary Background: To compare the results of cognitive testing of multiinfarct pts. with that of coronary pts. Methods and results: The study was performed on 50 persons. 25 righthanded, multifocal cerebral infarct pts. (mean age + SD: 63.4 + 9.39) were investigated, whose diagnosis was confirmed by MRI. Patients with serious residual stroke symptoms (aphasia, severe hemiparesis) were excluded (Rankin-scale > 3, MMSE 26.8 ± 1.5 mean ± SD). All nootropic drugs pre-
The aprosodias: Clinical manifestation and significance of the syndrome P. Tariska Memory Clinic, National Institute of Psychiatry and Neurology, Budapest, Hungary Prosody consists of different variations in sound pitch, stress and rhythm underlying speech melody and inflection [1]. The prosodic components of speech assist in inferring the attitude and emotion of the speaker and are
278
Abstracts / Journal of the Neurological Sciences 283 (2009) 240–320
vital in everyday communication. A review of the literature suggests that the left hemisphere is responsible for modulating the linguistic components of prosody (e.g., timing), whereas the right hemisphere is predominantly responsible for modulating the affective components of prosody (e.g., spectral information or pitch). Aprosodia, the inability to either produce or comprehend the affective components of speech or gesture, is a common occurrence after brain injury. The two basic forms are: executive and receptive ones. (2). Both forms are extremely important in the communication abilities of the patient. Receptive dysprosodia separates the patients from the emotions of others; motoric dysprosodia impairs the ability to adequately communicate. Disorders of affective aprosodia have been classified along the same dimensions as the aphasias. Bedside evaluation and neuroimaging have been used to identify and classify types of aprosodia. The treatment goals for aphasia may be adapted and applied to aprosodia. Additionally, pharma-cotherapy and biofeedback have been found useful in the treatment of aprosodia and associated features. Neuroanatomical basis of dysprosodias is widespread: several brain regions are involved (executive forms: frontal, hemisphere lesions, basal ganglia dysfunction, ce-rebellar lesion etc; receptive forms: right temporoparietal regions). Especially right temporo-parietal lesion can cause both forms of dysprosodias (3). Recent study highlighted the frequency of aprosody in patients suffering from Alzheimer's disease opposed to patients with vascular dementia (4). Short case history of 8 patients of the Memory Clinic is briefly presented having dysprosody of non-aphasic origin. Their observation underlays the heterogenic origin of the symptom that can be present in the frame of dementia disease, mild cognitive impairment of unknown origin, diseases of basal ganglia and furthermore mixed or pure psychogenic origin as well. References [1] Monrad-Crohn GH. Dysprosody or altered “melody of language”. Brain 70: 405–415, 1947.
doi:10.1016/j.jns.2009.02.147
Carotid stenosis and cognitive function
Detection of cerebral microbleeds in patients treated with oral anticoagulants
H. Werschinga, C. Stehlingb, S. Kloskab, L. Eckardtc, W. Heindelb, S. Knechta a Department of Neurology, University of Muenster, Muenster, Germany b Department of Clinical Radiology, University of Muenster, Muenster, Germany c Department of Cardiology and Angiology, University of Muenster, Muenster, Germany Background and aims: Cerebral microbleeds (CMBs) are perivascular hemosiderin deposits frequently detected in patients with intracerebral hemorrhage and ischemic cerebral infarction. If proven a marker for bleedingprone microangiopathy, CMBs might be of prognostic value in the therapeutic decision of anticoagulation. The purpose of our study was to evaluate the appearance of CMBs using Gradient echo T2⁎-weighted MRI in persons treated with oral anticoagulants without symptomatic cerebrovascular disease. Methods: We used the data of 494 elderly individuals (mean age 62 years, 247 male), who took part in an interdisciplinary population-based cohort study of healthy aging (SEARCH-Health). All subjects underwent clinical examination, neuropsychological testing and 3.0 T MRI. CMBs were defined as focal areas of low signal intensity on T2⁎MRI of less than 10 mm in diameter. White matter hyperintensities were calculated semiquantitatively. Results: Forty-nine individuals currently used oral anticoagulants. CMBs were found in 10 of 49 individuals with anticoagulation, and in 38 of 407 individuals without anticoagulation (p < .05); however, beside treatment with anticoagulants, advanced age and the presence of cardiovascular disease (arterial hypertension, arterial fibrillation, ischemic heart disease) was significantly more common in subjects with CMBs than in those without. Adjusting for these factors in logistic regression analysis showed that only arterial hypertension and ischemic heart disease were considered to be significant and independent predictors of CMBs. Furthermore subjects with CMBs had significantly more white matter intensities. Conclusions: In our study CMB prevalence is more than two times higher among patients with anticoagulative treatment compared to those without such a therapy. But it seems to be rather an effect of associated cardiovascular risk factors than a consequence of the anticoagulatory effect itself. This finding is supported by the fact, that the manifestation of CMBs in our study is highly correlated with the degree of white matter disease.
L.K. Sztriha Department of Neurology, University of Szeged, Szeged, Hungary
doi:10.1016/j.jns.2009.02.149
While stroke is a known cause of cognitive impairment, the relationship between carotid artery stenosis and cognitive function in people without a history of stroke is less clear. A number of risk factors for vascular disease are related to cognitive impairment. Hypertension, diabetes mellitus, cigarette smoking, and dyslipidemia are associated with an increased risk of carotid artery disease too. Some studies have suggested that stenosis of the internal carotid artery may be an independent risk factor for cognitive impairment. Cognitive impairment and decline tend to be more frequent with left-sided stenosis, if tests for dominant hemispheric function in right-handed individuals are utilized during the assessment. The possible pathomechanisms of cognitive impairment include silent embolization and hypoperfusion. High-grade stenosis of the internal carotid artery may be associated with cognitive impairment even without evidence of infarction on magnetic resonance imaging. On the other hand, it is fairly common that patients have normal cognition despite severe carotid artery disease, highlighting the important role of an efficient collateral blood supply. The carotid intimamedia thickness appears to be a marker of underlying risk factors and generalized atherosclerosis, rather than a direct cause of cognitive impairment. Carotid endarterectomy or stenting may lead to a decline in cognitive function due to microembolic ischemia or intraprocedural hypoperfusion. Conversely, restoring perfusion could improve cognitive dysfunction that might have occurred from a state of chronic hypoperfusion. It is unclear whether these complex interactions ultimately result in a net improvement or a deterioration of cognitive function. Evidence at present does not seem strong enough to include loss of cognition as a factor in determining the balance of risk and benefit from therapy for asymptomatic carotid stenosis.
Severe visuo-spatial impairment following a right occipital ischemic stroke: A new form of single strategic infarct dementia?
doi:10.1016/j.jns.2009.02.148
M. Marianetti, C. Mina, F. Micacchi, P. Marchione, P. Giacomini Department of Neurology and ORL/University of Rome, Rome, Italy Background and aims: Single Strategic Infarct Dementia is reported as a possible consequence of large strokes of anterior/lateral/subcortical cerebral areas having a key role for cognitive functioning (usually left/right angular gyrus, temporal lobes, frontal lobes, thalamus, caudatus, genu of left internal capsula). A correct neuropsychological classification of the disease is still lacking. Methods and results: We present the case of a 67-year-old, right handed woman, affected by hypertension and dyslipidemia, who two years before our observation started to suffer from cognitive impairment after a large right occipital ischemic stroke. Neurologically she presented a left homonymous hemianopsia and an evident visuospatial disturbance for which we administered her this neuropsychological test battery: Mini Mental State Examination, Rey's 15 Words Test (immediate and delayed recall), Rey's Complex Figure (copy, immediate recall and delayed recall), Attentive Matrices, Raven's Progressive Matrices, Frontal Assessment Battery, Phonological and Semantic Verbal Fluency Test, Trail Making Test A/B, Ideomotor and Orofacial Apraxia Test, Judgment of Line Orientation Test (JLOT), Street Completion Test, Recognition of Unknown Faces Test, Elaboration of Colors, Recognition of Facial Expressions, Recognition of Famous Faces and Famous Places, Clock Drawing Test, Line Bisection Test, Token Test, Boston Naming Test, Clinical Dementia Rating Scale(CDR). This battery revealed absence of neglect, a mild compromission of memory, attention and executive functions