- Email: [email protected]
Transient global amnesia during a professional cello concert
1260
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261
association between wakeboarding and ICA dissection, and foster further reporting of similar cases. References 1. Hostetler SG, Hostetler TL, Smith GA, et al. Characteristics of water skiing-related and wakeboarding-related injuries treated in emergency departments in the United States, 2001–2003. Am J Sports Med 2005;33:1065–70. 2. Chia JK, Goh KY, Chan C. An unusual case of traumatic intracranial hemorrhage caused by wakeboarding. Pediatr Neurosurg 2000;32:291–4.
3. Carson Jr WG. Wakeboarding injuries. Am J Sports Med. 2004;32:164–73. 4. Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003;61:1347–51. 5. Gonzales-Portillo F, Bruno A, Biller J. Outcome of extracranial cervicocephalic arterial dissections: a follow-up study. Neurol Res 2002;24:395–8. 6. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009;8:668–78. 7. Engelter ST, Brandt T, Debette S, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke 2007;38:2605–11. 8. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998;29:2646–8.
doi:10.1016/j.jocn.2011.02.013
Transient global amnesia during a professional cello concert Kiran Thakur, Allan Ropper ⇑ Brigham and Women’s Hospital, Department of Neurology, 75 Francis Street, Boston, Massachusetts 02115, USA
a r t i c l e
i n f o
Article history: Received 29 March 2010 Accepted 26 January 2011
Keywords: Memory Music Transient global amnesia
a b s t r a c t Transient global amnesia (TGA) is a great curiosity in medicine, the underlying pathophysiology of which remains under debate. When an episode occurs during the performance of a task requiring refined technical skills and an intense level of concentration such as a musical performance, it draws attention to the relationship between memory and performance. It also raises questions of access to procedural memory and other aspects of stored information. We encountered a renowned and highly proficient musician who was amnestic for a challenging concert. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Transient global amnesia (TGA) is a great curiosity in medicine, the underlying pathophysiology of which remains under debate. When an episode occurs during the performance of a task requiring refined technical skills and an intense level of concentration, such as a musical performance, it draws attention to the relationship between memory and performance. It also raises questions of access to procedural memory and other aspects of stored information. We encountered a renowned and highly proficient musician who was amnestic for a challenging concert. 2. Case report A 74-year-old right-handed world-renowned cellist was examined several days after he had transient memory loss that encompassed an entire musical performance. The patient had an exceptional natural ability in music when he began playing the cello at 15 years of age. He had advanced enough by the time he was 17 years old to attend Prades France, and studied at the Julliard School of music at 19 years. Following his training, he joined a nationally prominent orchestra when he was 28 years old. On the morning of the concert he remembers having breakfast with his wife and driving to the concert hall. He had his usual degree of anxiety prior to a performance, but otherwise felt well. Approximately half an hour prior to entering the stage, the patient spoke with the concert coordinator backstage. They discussed the pieces he was going to play and the patient expressed his nervous⇑ Corresponding author. Tel.: +1 617 732 8047; fax: +1 617 975 0978. E-mail address: [email protected] (A. Ropper).
ness to her. She did not appreciate any unusual behavior during their conversation. He went on stage at noon and recalls playing the first several notes of ‘‘Suite no. 3 in C major, BWV 1009, by Johann Sebastian Bach’’ but does not recall anything further of his 30 minute concert. The second piece, ‘‘Sonata for Solo Cello, Opus 8 by Zoltán Kodály’’, is considered by cognoscenti to be one of the hardest cello pieces ever written, requiring 30 minutes of continuous complex musicianship. Between the two pieces, he remained on stage and did not interact with anyone in the concert hall. There was a five minute intermission between the two pieces. The patient played both pieces from memory. According to audience members including his wife and a musician we interviewed, he played perfectly. After the performance he proceeded backstage to meet the concert director and repeatedly reintroduced himself to her. The concert director called the musician’s wife backstage because of this strange behavior. The patient appeared physically well and was oriented but could not provide any details of the musical pieces he had just performed. His wife asked their son to bring the patient home, now approximately three hours after the beginning of the performance. His son describes his father acting himself, not repeating questions, and able to direct him home. The only unusual behavior that the patient’s son noted was that he was unable to describe any details of the performance. The patient was able, days later, to report some memory of driving home with his son and recalls all events in the evening, four hours after the start of the concert. The following morning, he found that the two bottom strings of his cello were re-tuned to the lower register required for the Sonata by Kodály – this struck him as odd and was his only indication that he had played this piece the day before.
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261
One day after the event, his vital signs, orientation, fund of knowledge, naming, repetition, serial subtraction of sevens, praxis, and writing were normal. He knew the president, vice president, and secretary of state. On three-step Luria hand tasks, he reversed the first and second maneuvers until the fourth try. He was able to describe the precise route he drove to the concert hall. His memory for distant past events was preserved. At that time and again 1 week later he was unable to provide any information about the concert he had played and was aware of these events only by discussions with his wife. He had had a previous transient episode of memory loss 2.5 years previously while playing a Beethoven duet with his daughter on viola in concert. His wife recalls having tea after the concert and her husband asking repetitive questions such as ‘‘where are we?’’ and ‘‘what are we doing here?’’ He was unable to provide any information about the concert he had performed a few minutes previously. His symptoms lasted about 12 hours. He was seen in the emergency department and found to have a normal neurological examination athough he was unable to provide any details of his performance or events of the day. An brain MRI and magnetic resonance angiogram showed non-specific white matter changes and mild right internal carotid stenosis. 3. Discussion This eminent musician who had transient global amnesia during a complex musical performance is of interest beyond the exceptional circumstances in which the episode occurred. All the characteristics of the original descriptions of TGA offered by Benon in 1909 and by Fisher and Adams in 1958 occurred in the patient including anterograde amnesia and repetitive questioning. The diagnostic criteria for TGA offered by Hodges et al. include an attack witnessed by a observer of loss of recent memory, an absence of clouding of consciousness or other cognitive impairment, the absence of focal neurological signs or deficits during or after the attack, no features of epilepsy, and resolution of the attack within 24 hours.1,2 Attacks may be precipitated by the Valsalva maneuver, physical activity, or psychological stress.3 The concert venue was small, though formal, and not imbued with special meaning for the patient, having played there before. In our patient, a degree of anxiety prior to his musical performance and perhaps the need for phased breathing, including breath holding, could have been implicated but all of these circumstances were routine for the patient except for the difficulty of the pieces. Our patient endorses that while playing challenging pieces, his breathing pattern is altered in a manner that mimics the rhythmic patterns of the music. This change in breathing pattern may have caused decreased cerebral venous return. Chung et al. showed that left brachiocephalic vein occlusion caused retrograde venous flow and decreased cerebral venous return. In their study, abnormal intracranial retrograde venous flow was found in 50% of patients with TGA, but not in normal control subjects.4 Left brachiocephalic occlusion between the aortic arch and the sternum occurs during regular breathing and may be enhanced during breath holding. The recurrence of TGA is an interesting but not atypical feature of this patient. Interestingly, his first episode of TGA was during a musical performance as well. During both musical pieces, the patient varied his breathing pattern, perhaps increasing the likelihood of TGA by the mechanism described above. The function of memory in performing complex tasks is undoubtedly important. The role of memory in music was explored by Critchley and Henson.5 In their book, they describe various experiments that further our understanding of musicians’ ability to encode and remember music. They describe the necessity of having remote memories doi:10.1016/j.jocn.2011.01.009
1261
so that one can draw upon past auditory and visual experiences to invoke certain emotions. Recent memory helps identify references to previous material within a musical piece. However, the mechanisms by which we retrieve music from our general memory stores remains poorly understood. Audience members observing our patient’s performance noted not only technical perfection but also his own emotional connection to the music. The most artful musical performances are infused with feeling, with attunement to the composer’s style, and a musician’s own interpretation of the piece. Can any artistic or creative performance of this caliber be adequately explained by ‘‘procedural memory’’? Our musician describes practicing challenging pieces such as those played during this concert hundreds of times to engrain the pieces into his memory. He practices individual portions of these complicated pieces to create what he describes as a hierarchical scheme in his mind. Thus, he builds upon each preceding portion from the previous notes he has played. His ability to play the pieces from memory is derived from this hierarchical scheme. Like many musicians, the manner by which our patient practices these musical pieces makes it feasible to retrieve them from his long-term memory store and play with technical perfection. In contrast to the usual report of TGA, our patient did not pause to repeatedly inquire as to what portion of the performance he had completed. This may have been the result of the unusual circumstances of a solo musical performance without assistance. Alternatively, it offers an insight into the moment of onset of TGA. If the fundamental disorder begins during a procedure, it may perplex the patient in a way that obligates repetitive questioning; if it starts afterwards, retrograde amnesia may simply extend to the epoch of the act. It is indeed plausible that our patient experienced the onset of his amnestic episode towards the end of his performance or alternatively after his performance was completed. If this is the case, he experienced retrograde amnesia while he was playing the concert. His ability to retune his cello for the Kodály and his ability to play the two pieces sequentially suggests that his semantic memory function was intact. Previous studies have shown the short duration and temporal gradient of memory loss during the period of retrograde amnesia in TGA.6 Our study suggests that the period of retrograde amnesia was at least 50 minutes, a longer duration of retrograde amnesia than previously described. This case exemplifies the need for further exploration of the relation between musical memory and neuronal function. As has been remarked, ‘‘the great difficulty in the scientific study of the arts is that human perception of qualities and patterns is far ahead of anything which science can apprehend at the present time’’.7 Acknowledgement This report was written with the cooperation and assent of the patient. References 1. Hodges JR, Warlow CP. Syndromes of transient amnesia: towards a classification – a study of 153 cases. J Neurol Neurosurg Psychiatry 1990;53:834–43. 2. Hodges JR, Warlow CP. The etiology of transient global amnesia: a case control study of 114 cases with prospective follow-up. Brain 1990;113:639–57. 3. Lewis SL. Etiology of transient global amnesia. Lancet 1998;352:397–9. 4. Chung CP, Hsu HY, Chao AC, et al. Detection of intracranial venous reflux in patients of transient global amnesia. Neurology 2006;66:1873–7. 5. Critchley M, Henson RA, editors. Music and the brain: studies in the neurology of music. London: Heinemann; 1977. 6. Kritchevsky M, Squire LR. Transient global amnesia. Evidence for extensive, temporally graded retrograde amnesia. Neurology 1989;39:213. 7. Poser CM. The book forum. Music and the brain: studies in the neurology of music. JAMA 1977;238:1185.
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261
association between wakeboarding and ICA dissection, and foster further reporting of similar cases. References 1. Hostetler SG, Hostetler TL, Smith GA, et al. Characteristics of water skiing-related and wakeboarding-related injuries treated in emergency departments in the United States, 2001–2003. Am J Sports Med 2005;33:1065–70. 2. Chia JK, Goh KY, Chan C. An unusual case of traumatic intracranial hemorrhage caused by wakeboarding. Pediatr Neurosurg 2000;32:291–4.
3. Carson Jr WG. Wakeboarding injuries. Am J Sports Med. 2004;32:164–73. 4. Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003;61:1347–51. 5. Gonzales-Portillo F, Bruno A, Biller J. Outcome of extracranial cervicocephalic arterial dissections: a follow-up study. Neurol Res 2002;24:395–8. 6. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009;8:668–78. 7. Engelter ST, Brandt T, Debette S, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke 2007;38:2605–11. 8. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998;29:2646–8.
doi:10.1016/j.jocn.2011.02.013
Transient global amnesia during a professional cello concert Kiran Thakur, Allan Ropper ⇑ Brigham and Women’s Hospital, Department of Neurology, 75 Francis Street, Boston, Massachusetts 02115, USA
a r t i c l e
i n f o
Article history: Received 29 March 2010 Accepted 26 January 2011
Keywords: Memory Music Transient global amnesia
a b s t r a c t Transient global amnesia (TGA) is a great curiosity in medicine, the underlying pathophysiology of which remains under debate. When an episode occurs during the performance of a task requiring refined technical skills and an intense level of concentration such as a musical performance, it draws attention to the relationship between memory and performance. It also raises questions of access to procedural memory and other aspects of stored information. We encountered a renowned and highly proficient musician who was amnestic for a challenging concert. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Transient global amnesia (TGA) is a great curiosity in medicine, the underlying pathophysiology of which remains under debate. When an episode occurs during the performance of a task requiring refined technical skills and an intense level of concentration, such as a musical performance, it draws attention to the relationship between memory and performance. It also raises questions of access to procedural memory and other aspects of stored information. We encountered a renowned and highly proficient musician who was amnestic for a challenging concert. 2. Case report A 74-year-old right-handed world-renowned cellist was examined several days after he had transient memory loss that encompassed an entire musical performance. The patient had an exceptional natural ability in music when he began playing the cello at 15 years of age. He had advanced enough by the time he was 17 years old to attend Prades France, and studied at the Julliard School of music at 19 years. Following his training, he joined a nationally prominent orchestra when he was 28 years old. On the morning of the concert he remembers having breakfast with his wife and driving to the concert hall. He had his usual degree of anxiety prior to a performance, but otherwise felt well. Approximately half an hour prior to entering the stage, the patient spoke with the concert coordinator backstage. They discussed the pieces he was going to play and the patient expressed his nervous⇑ Corresponding author. Tel.: +1 617 732 8047; fax: +1 617 975 0978. E-mail address: [email protected] (A. Ropper).
ness to her. She did not appreciate any unusual behavior during their conversation. He went on stage at noon and recalls playing the first several notes of ‘‘Suite no. 3 in C major, BWV 1009, by Johann Sebastian Bach’’ but does not recall anything further of his 30 minute concert. The second piece, ‘‘Sonata for Solo Cello, Opus 8 by Zoltán Kodály’’, is considered by cognoscenti to be one of the hardest cello pieces ever written, requiring 30 minutes of continuous complex musicianship. Between the two pieces, he remained on stage and did not interact with anyone in the concert hall. There was a five minute intermission between the two pieces. The patient played both pieces from memory. According to audience members including his wife and a musician we interviewed, he played perfectly. After the performance he proceeded backstage to meet the concert director and repeatedly reintroduced himself to her. The concert director called the musician’s wife backstage because of this strange behavior. The patient appeared physically well and was oriented but could not provide any details of the musical pieces he had just performed. His wife asked their son to bring the patient home, now approximately three hours after the beginning of the performance. His son describes his father acting himself, not repeating questions, and able to direct him home. The only unusual behavior that the patient’s son noted was that he was unable to describe any details of the performance. The patient was able, days later, to report some memory of driving home with his son and recalls all events in the evening, four hours after the start of the concert. The following morning, he found that the two bottom strings of his cello were re-tuned to the lower register required for the Sonata by Kodály – this struck him as odd and was his only indication that he had played this piece the day before.
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261
One day after the event, his vital signs, orientation, fund of knowledge, naming, repetition, serial subtraction of sevens, praxis, and writing were normal. He knew the president, vice president, and secretary of state. On three-step Luria hand tasks, he reversed the first and second maneuvers until the fourth try. He was able to describe the precise route he drove to the concert hall. His memory for distant past events was preserved. At that time and again 1 week later he was unable to provide any information about the concert he had played and was aware of these events only by discussions with his wife. He had had a previous transient episode of memory loss 2.5 years previously while playing a Beethoven duet with his daughter on viola in concert. His wife recalls having tea after the concert and her husband asking repetitive questions such as ‘‘where are we?’’ and ‘‘what are we doing here?’’ He was unable to provide any information about the concert he had performed a few minutes previously. His symptoms lasted about 12 hours. He was seen in the emergency department and found to have a normal neurological examination athough he was unable to provide any details of his performance or events of the day. An brain MRI and magnetic resonance angiogram showed non-specific white matter changes and mild right internal carotid stenosis. 3. Discussion This eminent musician who had transient global amnesia during a complex musical performance is of interest beyond the exceptional circumstances in which the episode occurred. All the characteristics of the original descriptions of TGA offered by Benon in 1909 and by Fisher and Adams in 1958 occurred in the patient including anterograde amnesia and repetitive questioning. The diagnostic criteria for TGA offered by Hodges et al. include an attack witnessed by a observer of loss of recent memory, an absence of clouding of consciousness or other cognitive impairment, the absence of focal neurological signs or deficits during or after the attack, no features of epilepsy, and resolution of the attack within 24 hours.1,2 Attacks may be precipitated by the Valsalva maneuver, physical activity, or psychological stress.3 The concert venue was small, though formal, and not imbued with special meaning for the patient, having played there before. In our patient, a degree of anxiety prior to his musical performance and perhaps the need for phased breathing, including breath holding, could have been implicated but all of these circumstances were routine for the patient except for the difficulty of the pieces. Our patient endorses that while playing challenging pieces, his breathing pattern is altered in a manner that mimics the rhythmic patterns of the music. This change in breathing pattern may have caused decreased cerebral venous return. Chung et al. showed that left brachiocephalic vein occlusion caused retrograde venous flow and decreased cerebral venous return. In their study, abnormal intracranial retrograde venous flow was found in 50% of patients with TGA, but not in normal control subjects.4 Left brachiocephalic occlusion between the aortic arch and the sternum occurs during regular breathing and may be enhanced during breath holding. The recurrence of TGA is an interesting but not atypical feature of this patient. Interestingly, his first episode of TGA was during a musical performance as well. During both musical pieces, the patient varied his breathing pattern, perhaps increasing the likelihood of TGA by the mechanism described above. The function of memory in performing complex tasks is undoubtedly important. The role of memory in music was explored by Critchley and Henson.5 In their book, they describe various experiments that further our understanding of musicians’ ability to encode and remember music. They describe the necessity of having remote memories doi:10.1016/j.jocn.2011.01.009
1261
so that one can draw upon past auditory and visual experiences to invoke certain emotions. Recent memory helps identify references to previous material within a musical piece. However, the mechanisms by which we retrieve music from our general memory stores remains poorly understood. Audience members observing our patient’s performance noted not only technical perfection but also his own emotional connection to the music. The most artful musical performances are infused with feeling, with attunement to the composer’s style, and a musician’s own interpretation of the piece. Can any artistic or creative performance of this caliber be adequately explained by ‘‘procedural memory’’? Our musician describes practicing challenging pieces such as those played during this concert hundreds of times to engrain the pieces into his memory. He practices individual portions of these complicated pieces to create what he describes as a hierarchical scheme in his mind. Thus, he builds upon each preceding portion from the previous notes he has played. His ability to play the pieces from memory is derived from this hierarchical scheme. Like many musicians, the manner by which our patient practices these musical pieces makes it feasible to retrieve them from his long-term memory store and play with technical perfection. In contrast to the usual report of TGA, our patient did not pause to repeatedly inquire as to what portion of the performance he had completed. This may have been the result of the unusual circumstances of a solo musical performance without assistance. Alternatively, it offers an insight into the moment of onset of TGA. If the fundamental disorder begins during a procedure, it may perplex the patient in a way that obligates repetitive questioning; if it starts afterwards, retrograde amnesia may simply extend to the epoch of the act. It is indeed plausible that our patient experienced the onset of his amnestic episode towards the end of his performance or alternatively after his performance was completed. If this is the case, he experienced retrograde amnesia while he was playing the concert. His ability to retune his cello for the Kodály and his ability to play the two pieces sequentially suggests that his semantic memory function was intact. Previous studies have shown the short duration and temporal gradient of memory loss during the period of retrograde amnesia in TGA.6 Our study suggests that the period of retrograde amnesia was at least 50 minutes, a longer duration of retrograde amnesia than previously described. This case exemplifies the need for further exploration of the relation between musical memory and neuronal function. As has been remarked, ‘‘the great difficulty in the scientific study of the arts is that human perception of qualities and patterns is far ahead of anything which science can apprehend at the present time’’.7 Acknowledgement This report was written with the cooperation and assent of the patient. References 1. Hodges JR, Warlow CP. Syndromes of transient amnesia: towards a classification – a study of 153 cases. J Neurol Neurosurg Psychiatry 1990;53:834–43. 2. Hodges JR, Warlow CP. The etiology of transient global amnesia: a case control study of 114 cases with prospective follow-up. Brain 1990;113:639–57. 3. Lewis SL. Etiology of transient global amnesia. Lancet 1998;352:397–9. 4. Chung CP, Hsu HY, Chao AC, et al. Detection of intracranial venous reflux in patients of transient global amnesia. Neurology 2006;66:1873–7. 5. Critchley M, Henson RA, editors. Music and the brain: studies in the neurology of music. London: Heinemann; 1977. 6. Kritchevsky M, Squire LR. Transient global amnesia. Evidence for extensive, temporally graded retrograde amnesia. Neurology 1989;39:213. 7. Poser CM. The book forum. Music and the brain: studies in the neurology of music. JAMA 1977;238:1185.