Sleep benefit in Parkinson's disease

Sleep benefit (SB) In Parkinson's disease (PD) is not well characterized. To determine SB frequency, as well as to characterize and correlate it with other disease variables, we evaluated prospectively a consecutive series of 312 PD patients by means of a structured questionnaire: 55% reported having SB and 35% reported that awakening was their best time of the day. Because of SB, 21% of the entire population were able to skip or delay medication. The mean duration of the phenomenon was 85.4 +/- 67 min. Patients with SB were significantly older (p < 0.0002), had disease longer (p < 0.05), and were often men (chi 2 = 3.5, df 1, p = 0.05). Patients with SB took sleep medication with similar frequency as those without SB. There were no differences in hours of sleep or sleep latency. Sleep problems such as nightmares or somnambulism, but not the number of sleep awakenings, were similar in both groups. In conclusion, SB is a frequent phenomenon, especially in men, elderly patients, and patients with longer disease duration. SB enables the morning L-dopa dose to be postponed in approximately 50% of patients.

Anosognosia and procedural learning in Alzheimer's disease

Awareness of cognitive deficits may rely on the implicit learning of intellectual limitations, and anosognosia in Alzheimer's disease (AD) may result from deficits in implicit learning. To examine this hypothesis, a consecutive series of 55 patients with probable AD were divided into groups with mild (n = 13), severe (n = 12), or no anosognosia (n = 30) and were assessed with a neuropsychological battery that included tests of declarative and procedural learning. Whereas there were no significant between-group differences in tests of declarative learning (the Buschke Selective Reminding Test and the Benton Visual Retention Test), patients with severe anosognosia showed a significantly worse performance on procedural learning (as measured with the Maze Learning Test) and a test assessing set shifting abilities (the Wisconsin Card Sorting Test) than AD patients without anosognosia. The authors' results suggest that deficits in procedural learning and anosognosia in AD may result from dysfunction in habit-learning systems.

Comparison of subcutaneous apomorphine versus dispersible madopar latency and effect duration in Parkinson's disease patients: a double-blind single-dose study

Twelve parkinsonian patients with severely fluctuating symptoms were given a single dose of apomorphine or Dispersible Madopar on 2 consecutive days, to confirm the latter drug's usefulness in "off" period rescue. According to our results, apomorphine proved faster in reverting "off" periods and should still be regarded as the drug of choice for this treatment modality.

SPECT findings in Alzheimer's disease and Parkinson's disease with dementia

We examined, with single photon emission tomography (SPECT) and (99mTc)-HMPAO, 18 patients with idiopathic Parkinson's disease and no dementia (PD), 12 patients with PD and dementia, 24 patients with probable Alzheimer's disease (AD), and 14 controls. While the three patient groups showed significantly lower perfusion in frontal inferior and temporal inferior areas as compared to controls, both demented groups showed significantly more severe bilateral hypoperfusion in superior frontal, superior temporal and parietal areas as compared to non-demented PD patients and controls. On the other hand, no significant differences in cerebral perfusion were found between patients with AD and patients with PD and dementia. In conclusion, our findings demonstrated specific but similar cerebral perfusion deficits in demented patients with either AD or PD.

Two domains of anosognosia in Alzheimer's disease

OBJECTIVE

To examine the presence of different dimensions of unawareness in patients with probable Alzheimer's disease.

METHODS

A consecutive series of 170 patients with probable Alzheimer's disease were assessed with the anosognosia questionnaire-dementia (AQ-D) which includes items related to cognitive deficits and behavioural problems.

RESULTS

A factor analysis of the AQ-D produced two factors: a "cognitive unawareness" factor, which loaded on items of memory, spatial and temporal orientation, calculation, abstract reasoning, and praxis, and a "behavioural unawareness" factor which loaded on items of irritability, selfishness, inappropriate emotional display, and instinctive disinhibition. A stepwise forward regression analysis showed significant correlations between the cognitive unawareness factor and more severe cognitive deficits, delusions, and apathy, but less depression. On the other hand, the behavioural unawareness factor correlated significantly with higher mania and pathological laughing scores. Whereas the cognitive unawareness factor showed a significant correlation with cognitive tests assessing verbal comprehension and long term memory, and was significantly associated with a longer duration of illness, no significant correlations were found between the behavioural unawareness factor and the neuropsychological tasks.

CONCLUSION

Unawareness of cognitive deficits and unawareness of behavioural problems may constitute independent phenomena in Alzheimer's disease. Whereas unawareness of cognitive deficits is related to the severity of intellectual impairment and the presence of delusional apathetic mood, unawareness of behavioural problems may be part of a disinhibition syndrome.

Drug-induced parkinsonism in schizophrenic patients: motor response and psychiatric changes after acute challenge with L-Dopa and apomorphine

Acute single-dose response of drug-induced parkinsonism (DIP) to L-Dopa and apomorphine challenge was evaluated in a double-blind crossover study in 12 schizophrenic patients. There were two noteworthy negative findings. First, neither L-Dopa nor apomorphine produced significant improvements in DIP and second, no changes (neither improvement nor worsening) were found in patients' psychiatric status. Findings suggest that, for a stimulation dose reaching almost 90% of the responsive dose for idiopathic Parkinson's disease, no significant changes may reasonably be expected in the parkinsonism of schizophrenic patients treated with neuroleptic drugs.

Neuropsychological and psychiatric differences between Alzheimer's disease and Parkinson's disease with dementia

OBJECTIVE

To examine neuropsychological and neuropsychiatric differences between patients with probable Alzheimer's disease and patients with Parkinson's disease and dementia.

METHODS

Thirty three patients with probable Alzheimer's disease and 33 patients with Parkinson's disease and dementia were matched for age, sex, and mini mental state examination scores and given a battery of neuropsychological and neuropsychiatric tests.

RESULTS

Patients with Parkinson's disease with dementia had a significantly higher prevalence of major depression than patients with Alzheimer's disease; patients with Alzheimer's disease showed more severe anosognosia and disinhibition than patients with Parkinson's disease. Whereas no significant between group differences were found on tests of memory and language, demented patients with Parkinson's disease had a significantly greater impairment on a test of visual reasoning than patients with Alzheimer's disease.

CONCLUSION

There were significant psychiatric differences between patients with Alzheimer's disease and demented patients with Parkinson's disease, but neuropsychological differences were restricted to a single cognitive domain.

Catatonia in depression: prevalence, clinical correlates, and validation of a scale

OBJECTIVES

To examine the clinical correlates of catatonia in depression, to validate a scale for catatonia, and to assess the validity of the DSM-IV criteria of the catatonic features specifier for mood disorders.

METHODS

A series of 79 consecutive patients with depression and 41 patients with Parkinson's disease without depression were examined using the modified Rogers scale (MRS), the unified Parkinson's disease rating scale (UPDRS), and the structured clinical interview for DSM-III-R (SCID).

RESULTS

Sixteen of the 79 depressed patients (20%) had catatonia. Depressed patients with catatonia had significantly higher scores on the MRS than non-catatonic depressed patients matched for severity of depression, or non-depressed patients with Parkinson's disease matched for severity of motor impairment. Depressed patients with catatonia were older, had a significantly higher frequency of major depression, more severe cognitive impairments, and more severe deficits in activities of daily living than depressed non-catatonic patients. The DSM-IV criteria of catatonia separated depressed catatonic patients from patients with Parkinson's disease matched for motor impairment, with a specificity of 100%. Catatonic signs did not improve after apomorphine.

CONCLUSIONS

catatonia is most prevalent among elderly patients with severe depression. The study showed the validity of the MRS for the diagnosis of catatonia in depressed patients, as well as the specificity of the DSM-IV criteria of the catatonic features specifier.

Neuropsychological, psychiatric, and cerebral blood flow findings in vascular dementia and Alzheimer's disease

BACKGROUND AND PURPOSE

Psychiatric, neuropsychological, and cerebral blood flow differences between patients with ischemic vascular dementia (IVD) or Alzheimer's disease (AD) were examined.

METHODS

A consecutive series of patients who met either the criteria of the National Institute of Neurological Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association for probable AD or the State of California AD Diagnostic and Treatment Centers criteria for probable IVD were included in the study. Twenty consecutive patients with IVD were matched for age, sex, and Mini-Mental State Examination scores with 40 consecutive patients with probable AD. Patients underwent a psychiatric interview, a neuropsychological assessment, and single-photon emission CT imaging with 99mTc-hexamethylpropyleneamine oxime.

RESULTS

Patients with IVD showed significantly more severe anosognosia (P<.05) and emotional lability (P<.01) than AD patients, but no significant between-group differences were found in the frequency and severity of depression. IVD patients showed significantly more severe deficits in tests of planning, sequencing (P<.05), and verbal fluency (P<.05) as well as significantly more severe cerebral blood flow deficits in the basal ganglia (P<.01) and the frontal lobes (P<.001) than AD patients.

CONCLUSIONS

Patients with IVD showed a relatively more severe dysfunction of the frontal lobes as demonstrated by single-photon emission CT and expressed in specific psychiatric and neuropsychological changes than AD patients matched for age, sex, and severity of dementia.

A double-blind placebo-controlled study of clomipramine in depressed patients with Alzheimer's disease

Twenty-one depressed patients with probable Alzheimer's disease (AD) were randomized to receive a 6-week treatment with clomipramine or placebo in a study with a double-blind crossover design. Main outcome measures were Hamilton Depression, Mini-Mental State (MMSE), and Functional Independence Measure (FIM) scores. Mood improved significantly on both clomipramine and placebo, but clomipramine was significantly more effective than placebo during the first 6-week treatment period. Patients started on clomipramine maintained improvement during the washout and placebo periods, whereas patients started on placebo worsened during the washout period. However, patients on clomipramine showed significantly lower MMSE scores overall than patients on placebo. No significant drug effects were found on FIM scores. Clomipramine proved to be a useful treatment of depression in patients with probable AD.

A randomized, double-blind, placebo-controlled study of bromocriptine in nonfluent aphasia

We carried out a double-blind and placebo-controlled study of the efficacy of bromocriptine in the treatment of nonfluent aphasia. Seven patients received bromocriptine (up to 60 mg/d) and an identical placebo in a randomized order. End points were the number of content words, content units, and pauses > 3 seconds during the description of a figure; verbal naming; and verbal fluency. There were no significant benefits of bromocriptine over placebo in any of the variables examined.

Dissociation between declarative and procedural learning in dementia and depression

Declarative and procedural learning were assessed in patients with probable Alzheimer's Disease (AD) and major depression, patients with AD and no depression, patients with major depression but no dementia, and a group of age-comparable nondemented and nondepressed normal controls. AD patients showed significant deficits in declarative but not in procedural learning, while depressed nondemented patients showed the opposite pattern (i.e., a significantly worse procedural than declarative learning). Patients with both AD and major depression showed a similar learning pattern to the AD nondepressed group (relatively preserved procedural learning but severe deficits in declarative memory). These findings provide further evidence for the independence between declarative and procedural learning, and demonstrate their different vulnerability in dementia and depressive-like states.

Prevalence and clinical correlates of pathological affective display in Alzheimer's disease

This study examined the prevalence and correlates of pathological affect in Alzheimer's disease. A consecutive series of 103 patients with Alzheimer's disease were examined with a comprehensive psychiatric assessment that included the pathological laughing and crying scale (PLACS). Forty patients (39%) showed pathological affect: 25% showed crying episodes, and 14% showed laughing or mixed (laughing and crying) episodes. Patients with pathological affect crying showed significantly higher depression scores and a significantly higher frequency of major depression and dysthymia than patients with no pathological affect. Patients with mixed pathological affect showed significantly more subcortical atrophy on CT than patients with pathological affect crying. Forty seven per cent of the patients with pathological affect had no congruent mood disorder, and they showed a significantly longer duration of illness and more severe anosognosia than patients with pathological affect that was congruent with an underlying mood disorder. The study validates the PLACS, and shows the high prevalence of pathological affect in Alzheimer's disease.

Neuropsychiatric and neuropsychological correlates of delusions in Alzheimer's disease

We examined the prevalence, phenomenology, and clinical correlates of delusions in a consecutive series of 103 patients with probable Alzheimer's disease (AD). Patients were examined with the Present State Exam and the Dementia-Psychosis Scale. Twenty-one patients (20%) met DSM-III-R criteria for a delusional disorder. The most frequent delusion type was paranoid (71%), followed by hypochondriacal (67%), the Capgras syndrome (29%), house misidentification (29%), and grandiose delusions (29%). Out of the 21 AD patients with delusions, 76% had three or more different types of delusions simultaneously. The frequency of delusions was not significantly associated with age, education, or age at dementia onset, and the type and severity of cognitive impairments was similar for AD patients with and without delusions. However, AD patients with delusions had significantly higher mania and anosognosia scores.

A single-photon emission computed tomographic study of anosognosia in Alzheimer's disease

OBJECTIVE

To examine the presence of specific regional cerebral blood flow correlates of anosognosia in patients with probable Alzheimer's disease.

DESIGN

Case series, group comparisons.

SETTING

Ambulatory care referral center.

PATIENTS

Twelve patients with probable Alzheimer's disease and anosognosia and 12 patients with probable Alzheimer's disease without anosognosia who were matched for age, duration of illness, and cognitive impairments.

MAIN OUTCOME MEASURES

Single-photon emission computed tomographic scan studies with technetium Tc 99m hexamethylpropylene-amine oxime and regional cerebral blood flow measurements.

RESULTS

Patients with Alzheimer's disease and anosognosia showed significant blood flow deficits in the frontal inferior and superior (dorsal) areas of the right hemisphere. On the other hand, no significant between-group differences were found in depression scores and neuropsychological tasks that assessed verbal and visual memory, verbal comprehension, naming, verbal fluency, auditory attention, abstract reasoning, and set-shifting abilities.

CONCLUSIONS

Our study demonstrates that anosognosia may not be related to deficits in specific cognitive domains, but it may result from dysfunction of the right frontal lobe.

A SPECT study of parkinsonism in Alzheimer's disease

The authors examined the presence of significant regional cerebral blood flow (rCBF) differences between Alzheimer's disease (AD) patients with and without extrapyramidal signs (EPS). Nine patients with probable AD and EPS (resting tremor or rigidity and bradykinesia) and 9 AD patients without EPS, comparable in age, duration of illness, and global cognitive decline, were studied with [99mTc]HMPAO SPECT. Patients with AD and EPS showed significantly lower rCBF in the superior frontal, superior temporal, and parietal regions of the left hemisphere than AD patients without EPS. Rigidity and bradykinesia independently accounted for the decreased rCBF in these areas. These findings suggest that the presence of EPS in AD may result from dysfunction in specific brain regions.

Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease

OBJECTIVE

The purpose of this study was to examine the prevalence, risk factors, and correlates of depression among patients with Alzheimer's disease.

METHOD

A consecutive series of 103 patients with probable Alzheimer's disease were examined with a structured psychiatric interview and were assessed for the presence of cognitive impairments, deficits in activities of daily living, social functioning, and anosognosia.

RESULTS

Fifty-one percent of the patients had depression (28% had dysthymia and 23% major depression). Women had a significantly higher prevalence of both major depression and dysthymia than men. Depressed and nondepressed patients had a similar frequency of family and personal histories of depression, a similar frequency of personality disorders before the onset of depression, and no significant differences in cognitive deficits and impairment in activities of daily living. Dysthymia usually started after the onset of dementia and was significantly more prevalent in the early stages of dementia; patients with dysthymia had a significantly better awareness of intellectual deficits than patients with major or no depression. On the other hand, patients with major depression had an earlier onset of depression (half of them before the onset of dementia), and the prevalence of major depression was similar across the different stages of the illness.

CONCLUSIONS

This study demonstrates a high prevalence of dysthymia and major depression among patients with probable Alzheimer's disease. While dysthymia may be an emotional reaction to the progressive cognitive decline, major depression may be related to biological factors.

Anosognosia in Alzheimer's disease: a study of associated factors

The authors examined the prevalence and correlates of anosognosia in a consecutive series of patients with probable Alzheimer's disease (AD). Patients were examined with the Anosognosia Questionnaire-Dementia (AQ-D), which showed good reliability and validity. On the basis of the AQ-D scores, patients were divided into those with anosognosia (n = 21) and those without anosognosia (n = 52). Patients with anosognosia showed a significantly longer duration of illness, more severe cognitive impairments and deficits in activities of daily living, and higher mania and pathological laughing scores than AD patients without anosognosia. These findings suggest that anosognosia in AD may be part of a specific neuropsychiatric syndrome.

Extrapyramidalism in Alzheimer's disease: prevalence, psychiatric, and neuropsychological correlates

The prevalence and clinical correlates of extrapyramidal signs in a consecutive series of 78 patients with Alzheimer's disease attending a neurology clinic, and 20 age comparable normal controls, were examined. Based on the unified Parkinson's disease rating scale (UPDRS) findings, 18 patients (23%) met criteria for parkinsonism, 44 (56%) had isolated extrapyramidal signs, and 16 (21%) had no extrapyramidal signs. Whereas the control group showed a similar prevalence of isolated extrapyramidal signs (57%), none of them showed parkinsonism. No significant differences were found for age, sex, duration of illness, and severity of dementia among the three Alzheimer's disease groups. Patients with Alzheimer's disease-parkinsonism, however, showed a significantly higher frequency of major depression and dysthymia and significantly higher Hamilton depression scores than patients with isolated or no extrapyramidal signs. Patients with Alzheimer's disease-parkinsonism also showed significantly more deficits on frontal lobe related tasks such as the Wisconsin card sorting test, trail making test, and verbal fluency, as well as on tests of constructional praxis and abstract reasoning than patients with Alzheimer's disease but no extrapyramidal signs. In conclusion, the study showed a specific association between Alzheimer's disease and parkinsonism, as well as significant relations between parkinsonism, deficits in executive functions, and depression among patients with Alzheimer's disease.

A SPECT study of delusions in Alzheimer's disease

Although delusions are a frequent finding in patients with Alzheimer's disease (AD), their mechanism is not well known. We carried out Tc 99m HMPAO single-photon emission computed tomography studies in 16 AD patients with delusions and 29 AD patients without delusions comparable in age, years of education, duration of illness, and severity of dementia. Although we found no significant between-group differences in performance on neuropsychological tasks, AD patients with delusions had significantly lower mean cerebral blood flow in both the left and right temporal lobes.

Specificity of changes in cerebral blood flow in patients with frontal lobe dementia

Eight patients with a clinical diagnosis of probable Alzheimer's disease, eight patients with the clinical diagnosis of frontal lobe dementia, and eight controls were examined with single photon emission tomography (SPECT) using 99Tc-HMPAO. Patients with Alzheimer's disease and those with frontal lobe dementia met DSM-III-R criteria for mild dementia and were in the early stages of the illness. Compared with patients with Alzheimer's disease, the group with frontal lobe dementia had significantly lower blood flow in the frontal lobes (dorsolateral and orbital), the anterior temporal cortex, and the basal ganglia. Within the frontal lobe dementia group, blood flow was significantly lower in the orbital than in the dorsal frontal cortex, and in the anterior temporal than in the dorsal temporal cortex. The present study shows the specificity of changes in regional cerebral blood flow in the diagnosis of different types of dementia, and supports the importance of orbitofrontal, anterior temporal, and basal ganglia dysfunction in the production of the psychiatric syndrome of frontal lobe dementia.

The nature of apraxia in corticobasal degeneration

Although apraxia is one of the most frequent signs in corticobasal degeneration, the phenomenology of this disorder has not been formally examined. Hence 10 patients with corticobasal degeneration were studied with a standardised evaluation for different types of apraxia. To minimise the confounding effects of the primary motor disorder, apraxia was assessed in the least affected limb. Whereas none of the patients showed buccofacial apraxia, seven showed deficits on tests of ideomotor apraxia and movement imitation, four on tests of sequential arm movements (all of whom had ideomotor apraxia), and three on tests of ideational apraxia (all of whom had ideomotor apraxia). Ideomotor apraxia significantly correlated with deficit in both the mini mental state examination and in a task sensitive to frontal lobe dysfunction (picture arrangement). Two of the three patients with ideomotor apraxia and ideational apraxia showed severe cognitive impairments. The alien limb behaviour was present only in patients with ideomotor apraxia. In conclusion, ideomotor apraxia is the most frequent type of apraxia in corticobasal degeneration, and may be due to dysfunction of the supplementary motor area. There is a subgroup of patients with corticobasal degeneration who have a severe apraxia (ideomotor and ideational apraxia), which correlates with global cognitive impairment, and may result from additional parietal or diffuse cortical damage.

Masticatory muscle spasm in a non-Japanese patient with Satoyoshi syndrome successfully treated with botulinum toxin

A non-Japanese patient with Satoyoshi syndrome is presented. Severe masticatory muscle spasms interfered with feeding, but were successfully treated with botulinum toxin.

Bromocriptine-induced dystonia in patients with aphasia and hemiparesis

Five of seven patients with chronic nonfluent aphasia and hemiparesis due to a focal ischemic infarction developed painful hemidystonia during treatment with a high dose of bromocriptine. All seven patients had cortical damage, but four also had basal ganglia and one thalamic involvement. While lesion location did not differ between dystonic and nondystonic patients, the dystonic patients had more weakness than those without dystonia.

Apathy following cerebrovascular lesions

BACKGROUND AND PURPOSE

Although apathy has been reported to constitute a frequent sequela of stroke lesions, there have been no prospective studies on the frequency and correlates of apathy after stroke lesions. In the present study, we examined the frequency and correlates of apathy in a consecutive series of 80 patients with cerebrovascular lesions.

METHODS

We included patients within the first 10 days after a stroke lesion. Patients were examined with a comprehensive neuropsychiatric battery that included the Apathy Scale.

RESULTS

Eighteen patients (22.5%) showed apathy, nine of whom were also depressed. On the other hand, 18 patients (22.5%) showed depression in the absence of apathy. Although depression and apathy may exist independent of one another, major depression (but not minor depression) was associated with an increased frequency of apathy. Apathy was also significantly associated with older age, cognitive impairments, and deficits in activities of daily living. Finally, apathy was significantly associated with lesions in the posterior limb of the internal capsule.

CONCLUSIONS

These findings demonstrate that apathy is a frequent finding among patients with acute stroke lesions and may coexist with important emotional and cognitive poststroke disturbances.

Paroxysmal alien hand syndrome

Four patients are described who presented with a paroxysmal form of the alien hand syndrome. Two patients with damage to one frontomedial cortex had brief episodes of abnormal motor behaviour of the contralateral arm that featured groping, grasping, and apparently purposeful but perseverative movements, which both patients interpreted as alien or foreign. The other two patients, with posterior parietal damage, reported a paroxysmal feeling of unawareness of the location of the contralateral arm, lack of recognition of the arm as their own, purposeless movements, and personification of the arm. These cases represent a new form of the alien hand syndrome manifested by brief, paroxysmal episodes, which may be due to ictal mechanisms.

Inverse masticatory muscle activity due to syringobulbia

The clinical, radiological, and electrophysiological data of a 25-year-old woman with "inverse masticatory muscle activity" due to syringobulbia is presented. This uncommon brain stem syndrome may be due to a disturbance in central programming of mastication.

Abnormal sympathetic skin response in patients with autoimmune vitiligo and primary autoimmune hypothyroidism

The sympathetic skin response was studied in 21 patients with autoimmune vitiligo or hypothyroidism or both. No response to stimulation was found in 6 patients, but 4 with both diseases showed abnormal results. Sympathetic skin response is useful in evaluating sudomotor activity of the autonomic nervous system, and it is concluded that patients with autoimmune vitiligo, autoimmune hypothyroidism and especially those with both diseases show evidence of sudomotor dysfunction.

Catastrophic reaction after cerebrovascular lesions: frequency, correlates, and validation of a scale

The frequency and correlates of the catastrophic reaction (CR) were examined in 52 consecutive patients with an acute stroke lesion. A new scale proved reliable for measuring the severity of CR. The CR was significantly associated with depression, a personal and family history of psychiatric disorder, and subcortical lesions, which were mostly located in the basal ganglia. Patients with and without a CR, when matched for the presence and type of depression, differed only in that CR patients had significantly more anterior lesions and a significantly higher frequency of subcortical damage. Results demonstrate that the CR is significantly associated with poststroke depression and may be a specific manifestation of certain types of poststroke depression.

Neuropsychological correlates of brain atrophy in Parkinson's disease: a CT-scan study

We examined the presence of cortical or subcortical brain atrophy (as shown by CT scans) in patients with Parkinson's disease (PD) and assessed whether there were significant correlations between CT measurements and the presence of cognitive deficits. There were three main findings. First, patients with bilateral symptoms of PD showed more severe cortical and subcortical atrophy than age-matched normal controls. Second, the presence of unilateral symptoms of PD was significantly associated with contralateral brain atrophy only in patients with right hemi-PD. Third, there was a significant correlation between neuropsychological deficits and atrophy in specific brain areas.

SPECT findings in patients with primary mania

Five patients with a manic episode and 7 age-comparable control subjects were studied with single-photon emission computed tomography and [99mTc]d,l-hexamethylpropyleneamine oxime. Manic patients showed significantly lower blood flow in the basal portion of the right temporal lobe compared with normal control subjects. Moreover, manic patients showed a left-right asymmetry (a significantly lower perfusion in the right versus left temporal basal cortex), as well as a dorsal-ventral asymmetry (a significantly lower perfusion in the right temporal basal versus dorsal cortex). These findings suggest that the right basotemporal cortex may play an important role in the production of primary mania.

Anosognosia in patients with cerebrovascular lesions. A study of causative factors

BACKGROUND AND PURPOSE

Psychological and biological hypotheses have been proposed to explain anosognosia. We correlated the presence of anosognosia with the presence and severity of psychiatric disturbances, neglect, intellectual impairments, and computed tomographic evidence of lesion size, location, and measurements of brain atrophy.

METHODS

A series of 80 patients with acute stroke were assessed using a battery of psychiatric and neuropsychological tests and computed tomography.

RESULTS

There were five main findings. First, 27 (28%) of the 96 patients originally screened showed anosognosia. Second, patients with anosognosia had significantly higher frequencies of hemispatial neglect and related phenomena, as well as deficits in recognizing facial emotions and in receptive prosody. Third, depression was equally frequent among patients with and without anosognosia. Fourth, patients with anosognosia had a significantly higher frequency of right hemisphere lesions, primarily involving the temporoparietal junction, thalamus, and basal ganglia. Fifth, patients with anosognosia showed significantly more subcortical brain atrophy, primarily involving the frontal white matter and diencephalic areas.

CONCLUSIONS

The present study demonstrates that anosognosia does not "protect" stroke patients from depressive feelings; rather, it represents arousal-attentional disorders after lesions in specific areas of the right hemisphere in nonaphasic patients with preexisting subcortical atrophy.

Gyratory epilepsy in a patient with a thalamic neoplasm

A patient with a right thalamic oligodendroglioma developed seizures characterized by circling behavior, speech arrest, and secondarily generalized seizures. Gyratory epilepsy is relatively uncommon and may either represent a benign form of primary generalized epilepsy or occur secondary to a focal cortical lesion. Thalamic stimulation has been shown experimentally to induce circling movements, but no other clinical cases with a thalamic lesion have been described.

A prospective longitudinal study of depression, cognitive decline, and physical impairments in patients with Parkinson's disease

A consecutive series of 105 patients with Parkinson's disease were examined for the presence of affective disorders, cognitive deficits, and impairments in activities of daily living (ADLs); 92 received the same evaluation 12 months after the initial examination. On the basis of the initial psychiatric findings, patients were divided into major, minor, and non-depressed groups. Patients with major depression showed a significantly greater cognitive decline, deterioration in ADLs, and further advance through the Hoehn and Yahr stages than patients with either minor depression or no depression.

Impaired levodopa response in Parkinson's disease during melanoma therapy

A patient with melanoma and sporadic positive melanuria developed Parkinson's disease. Treatment with levodopa failed to modify tumoral progress. However, during chemotherapy with dacarbazine, the patient experienced a significant impairment to levodopa response.

Reliability, validity, and clinical correlates of apathy in Parkinson's disease

The authors examined a consecutive series of 50 patients for the presence of apathy, depression, anxiety, and neuropsychological deficits using a neuropsychological battery that included a recently designed apathy scale. This scale was found to be reliable and valid in the diagnosis of apathy in patients with PD. Of patients in the study, 12% showed apathy as their primary psychiatric problem, and 30% were both apathetic and depressed. Patients with apathy (with or without depression), showed significantly more deficits in both tasks of verbal memory and time-dependent tasks. Results suggest that apathy is a frequent finding in PD, is significantly associated with specific cognitive impairments, and may have a different mechanism than depression.

Subarachnoid and intramedullary cysts secondary to epidural anesthesia for gynecological surgery

Three women who received epidural anesthesia for gynecological surgery developed spinal arachnoiditis leading to subarachnoid cysts and cord cavitation. MRI was useful to show the subarachnoid and intramedullary cysts, as well as to monitor lesion extent and progress. Associated MRI findings were a Chiari anomaly in 1 case and a tethered cord in another. Two cases underwent surgery: 1 improved, but the other suffered progressive neurological deterioration. Although the 3rd patient had no treatment, there was spontaneous reduction in cavity size and clinical improvement. Careful handling of this procedure is urged to avoid such severe complications in young mothers.

Alzheimer's disease in a patient with posterior cortical atrophy

Posterior cortical atrophy (PCA) is characterised by slowly progressive dementia with cognitive and perceptual deficits suggestive of bilateral parieto-occipital disease. A case is reported of a patient with PCA and neuropathological findings consistent with Alzheimer's disease.

Cardiovascular reflexes and pudendal evoked responses in chronic haemodialysis patients

The bulbocavernous reflex (BCR), cortical pudendal evoked responses (CPERs), non-invasive cardiovascular tests and nerve conduction studies were performed in 16 patients on chronic haemodialysis and in a group of normal subjects. BCR and CPERs were more severely affected in patients with impotence. There was a significant correlation between the Valsalva ratio and P1 latency of the CPERs. The BCR and CPERs are alternative techniques for the assessment of impotence in uremic patients.

Transcortical aphasia. Importance of the nonspeech dominant hemisphere in language repetition

While a relative preservation of repetition in acute transcortical aphasia (TA) has usually been associated with the functional integrity of the speech dominant (left) perisylvian area, recent amytal data (Bando et al., 1986) have suggested a fundamental role of the nondominant (right) hemisphere in language repetition. The neuroradiological correlates of repetition were studied in a consecutive series of 21 patients with acute TA. A similar frequency of either perisylvian or extraperisylvian pathology was found. In 2 patients with perisylvian pathology, the injection of amytal in the hemisphere contralateral to the lesion abolished repetition. Positron emission tomography (PET) in another patient revealed marked hypometabolism over the entire left cortical mantle ipsilateral to a basal ganglia lesion, suggesting that preserved repetition was carried out by right hemisphere structures. This was confirmed in a second patient with left extraperisylvian pathology, in whom a second lesion in the right hemisphere resulted in impaired repetition. These findings suggest that the spared contralateral hemisphere may subserve residual repetition in some transcortical aphasic patients with a lesion within or outside the speech-dominant perisylvian area.

Mania after brain injury: neuroradiological and metabolic findings

We present a consecutive series of 8 patients who developed a manic episode after a brain injury. Five patients had cortical lesions (4 with damage to the right basotemporal region, and 1 with bilateral damage to the orbitofrontal area). While the other 3 patients had subcortical lesions (white matter of the right frontal lobe, right anterior limb of the internal capsule, and right head of the caudate), a fluorodeoxyglucose positron emission tomography scan showed hypometabolism in the right lateral basotemporal region in all 3 patients. These findings suggest a major role for the basal region of the right temporal lobe in the modulation of mood.

Acute CNS infection by Trypanosoma cruzi (Chagas' disease) in immunosuppressed patients

Acute CNS involvement by Trypanosoma cruzi is uncommon. We report 2 immunosuppressed patients, 1 adult who developed an acute meningoencephalitis, and 1 child who presented with the tumor-like form of the disease. Both patients acquired the disease through blood transfusion. Blood donors migrating from endemic areas can transmit the disease in nonendemic countries if they are not routinely screened for antibodies to T cruzi.

Developmental cortical anomalies in Asperger's syndrome: neuroradiological findings in two patients

Recent neuropathological and magnetic resonance imaging (MRI) studies have demonstrated developmental disturbances of neuronal migration in the cerebral cortex of autistic subjects. We report neuroradiological findings in two patients with Asperger's syndrome, a less severe variant of autism. One patient had left frontal macrogyria; the other had bilateral opercular polymicrogyria. A computer tomography (CT) scan performed on one of the patients' first-degree relatives (who had a bipolar disease) also showed cortical migration anomalies.

Anterior callosal haemorrhage. A partial interhemispheric disconnection syndrome

The interhemispheric disconnection syndrome secondary to a callosal haemorrhage is exceedingly uncommon. In the present study, 3 patients with haemorrhages restricted to the corpus callosum are presented. All 3 developed a partial anterior interhemispheric disconnection syndrome: unilateral tactile anomia, unilateral agraphia, unilateral apraxia, difficulty in copying drawings, dyscalculia as well as abnormalities of somaesthetic transfer and the 'alien hand' sign. The study of these cases allowed a close examination of the association between deficits in the transfer of specific neuropsychological information and the precise topography of callosal damage. Variability in the lateralization of cognitive functions, and possible mechanisms underlying the production of callosal haemorrhages after the rupture of saccular aneurysms are also discussed.

Evoked potentials, reaction time and cognitive performance in on and off phases of Parkinson's disease

Seven patients with Parkinson's disease and severe motor fluctuations were studied with event-related potentials, reaction and movement times and neuropsychological tests while in "off" and "on" phases. While there was a significant decrement in the P300 latency of the event-related potentials and in the duration of movement time in the "on" phase, no significant differences between on and off phases were observed in reaction time and neuropsychological tasks.

Emotional behavior after a Wada test in a patient with secondary mania

Soon after treatment of a right basotemporal vascular malformation using an embolization procedure, a 25-year-old patient developed an acute episode of mania. Two months later the patient was still manic, and a second embolization was scheduled. Before it was conducted, a Wada test was carried out to determine speech dominance. No changes in manic symptoms were observed after amytal injections into the left middle cerebral, right frontopolar, or right middle cerebral arteries. This finding suggests that secondary mania may not be the result of "release" of the left hemisphere following a right hemisphere lesion but instead may be related to specific disturbances within the right hemisphere.