Obsessive-compulsive behaviour and cognitive impairment in a parkinsonian patient after left putaminal lesion

The Caudate Nucleus: Its Connections, Surgical Implications, and Related Complications

BACKGROUND

The caudate nucleus is a C-shaped structure that is located in the center of the brain and is divided into 3 parts: the head, body, and tail.

METHODS

We detail the anatomic connections, relationships with other basal ganglia structures, and clinical implications of injury to the caudate nucleus.

RESULTS

Anatomically, the most inferior transcapsular gray matter is the lentiform peduncle, which is the connection between the lentiform nucleus and caudate nucleus as well as the amygdala. The border between the tail and body of the caudate nucleus is the posterior insular point. The tail of the caudate nucleus is extraependymal in some parts and intraependymal in some parts of the roof of the temporal horn of the lateral ventricle. The tail of the caudate nucleus crosses the inferior limiting sulcus (temporal stem), and section of the tail during approaches to lesions involving the temporal stem may cause motor apraxia. The mean distance from the temporal limen point, which is the junction of the limen insula and inferior limiting sulcus, to the tail of the caudate nucleus in the temporal stem is 15.87 ± 3.10 mm.

CONCLUSIONS

Understanding of the functional anatomy and connections of the distinct parts of the caudate nucleus is essential for deciding the extent of resection of lesions involving the caudate nucleus and the types of deficits that may be found postoperatively.

Impact of putamen stroke on task context updating: Evidence from P300 brain waves

According to the context updating theory, the oddball P300 component indexes brain activities underlying revision of the mental representation induced by incoming stimuli. It involves an attention-driven comparison process that evaluates the representation of the previous event in working memory. Delayed latencies have been reported for various types of stroke such as unilateral thalamic stroke. We investigated memory updating effects in patients with putamen stroke. Two groups of patients with putamen and thalamic stroke were recruited along with two control groups of young and old healthy participants. Auditory and visual P300 were elicited respectively in a two-stimulus oddball paradigm. The auditory P300 peak latencies were significantly longer in patients with a putamen lesion than in the aged and young control groups and the same pattern was found in the thalamus-lesioned patient. The delayed auditory P300 component in both patient groups but neither control group suggests impairment of memory updating in patients with putamen stroke comparable with thalamic stroke. Our study illustrates the important role of subcortical structures subserved in context updating.

Multimodal voxel-based meta-analysis of white matter abnormalities in obsessive-compulsive disorder

White matter (WM) abnormalities have long been suspected in obsessive-compulsive disorder (OCD) but the available evidence has been inconsistent. We conducted the first multimodal meta-analysis of WM volume (WMV) and fractional anisotropy (FA) studies in OCD. All voxel-wise studies comparing WMV or FA between patients with OCD and healthy controls in the PubMed, ScienceDirect, Google Scholar, Web of Knowledge and Scopus databases were retrieved. Manual searches were also conducted and authors were contacted soliciting additional data. Thirty-four data sets were identified, of which 22 met inclusion criteria (five of them unpublished; comprising 537 adult and pediatric patients with OCD and 575 matched healthy controls). Whenever possible, raw statistical parametric maps were also obtained from the authors. Peak and raw WMV and FA data were combined using novel multimodal meta-analytic methods implemented in effect-size signed differential mapping. Patients with OCD showed widespread WM abnormalities, but findings were particularly robust in the anterior midline tracts (crossing between anterior parts of cingulum bundle and body of corpus callosum), which showed both increased WMV and decreased FA, possibly suggesting an increase of fiber crossing in these regions. This finding was also observed when the analysis was limited to adult participants, and especially pronounced in samples with a higher proportion of medicated patients. Therefore, patients with OCD may have widespread WM abnormalities, particularly evident in anterior midline tracts, although these changes might be, at least in part, attributable to the effects of therapeutic drugs.

Pathological generosity: an atypical impulse control disorder after a left subcortical stroke

Changes in socio-emotional behavior and conduct, which are characteristic symptoms of frontal lobe damage, have less often been described in patients with focal subcortical injuries. We report on a case of pathological generosity secondary to a left lenticulocapsular stroke with hypoperfusion of several anatomically intact cortical areas. A 49-year-old man developed excessive and persistent generosity as he recovered from a left lenticulocapsular hematoma. His symptoms resembled an impulse control disorder. (99m)Tc-HMPAO SPECT demonstrated hypoperfusion mostly in the ipsilateral striatum, dorsolateral, and orbitofrontal cortex. This case study adds pathological generosity to the range of behavioral changes that may result from discrete unilateral lesions of the lenticular nucleus and nearby pathways. In our particular case, post-stroke pathological generosity was not ascribable to disinhibition, apathy, mania, or depression. Because pathological generosity may lead to significant distress and financial burden upon patients and their families, it may warrant further consideration as a potential type of impulse control disorder.

Neurosurgical targets for compulsivity: what can we learn from acquired brain lesions?

Treatment efficacy of deep brain stimulation (DBS) and other neurosurgical techniques in refractory obsessive-compulsive disorder (OCD) is greatly dependent on the targeting of relevant brain regions. Over the years, several case reports have been published on either the emergence or resolution of obsessive-compulsive symptoms due to neurological lesions. These reports can potentially serve as an important source of insight into the neuroanatomy of compulsivity and have implications for targets of DBS. For this purpose, we have reviewed all published case reports of patients with acquired or resolved obsessive-compulsive symptoms after brain lesions. We found a total of 37 case reports describing 71 patients with acquired and 6 with resolved obsessive-compulsive symptoms as a result of hemorrhaging, infarctions or removal of tumors. Behavioral symptoms following brain lesions consisted of typical obsessive-compulsive symptoms, but also symptoms within the compulsivity spectrum. These data suggests that lesions in the cortico-striato-thalamic circuit, parietal and temporal cortex, cerebellum and brainstem may induce compulsivity. Moreover, the resolution of obsessive-compulsive symptoms has been reported following lesions in the putamen, internal capsule and fronto-parietal lobe. These case reports provide strong evidence supporting the rationale for DBS in the ventral striatum and internal capsule for treatment of compulsivity and reveal the putamen and fronto-parietal cortex as promising new targets.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of mania: which one(s) result(s) more often from right than left hemisphere lesions?

Previously published single case reports of patients with a unilateral lesion were assembled. After the lesion, each of the 244 cases presented at least one of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of a manic episode, namely, elated or irritable mood, grandiosity, talkativeness, flight of ideas, hyperhedonism, reduced need for sleep, agitation, or distractibility (all optional in DSM-IV). As expected, the subgroup of 59 manic patients had a right hemisphere lesion far more often than a left one. However, this was also true of various sets of the nonmanic cases. Furthermore, elation was not the symptom most strongly associated with lesion side. Elation without mania was not significantly predicted by lesion side. However, talkativeness was strongly predicted by right lesion side whether in manic or nonmanic patients or even when the symptom was the only symptom observed. Agitation was consistently and robustly associated with right lesion side, but not completely distinctly so (it fell short of significance when not accompanied by elation or other symptoms). It is proposed that prevalence of right hemisphere lesions causing mania is primarily related to mental and behavioral disinhibition rather than a shift of mood and that it consists of release of left hemisphere influence.

An orbitofrontostriatopallidal pathway for morality: evidence from postlesion antisocial and obsessive-compulsive disorder

INTRODUCTION

A detailed proposal is made to the effect that nonlesional antisocial personality disorder (APD) is, among other things, a dysfunctional hypomoralism and that nonlesional obsessive-compulsive disorder (OCD) is, among other things, a dysfunctional hypermoralism.

METHOD

To provide an empirical test of this proposal, 25 previously published cases of acquired (post lesion) APD and 39 cases of acquired OCD are reviewed and compared with multivariate inference tests.

RESULTS

The acquired APD patients most often present putamenal or pallidal lesions.

CONCLUSION

The ensemble of neurobiological, endocrine, and behavioural traits in APD and OCD, as well as the distinct lesion sites in the acquired variants, support the notion of an orbitofrontostriatopallidal brain system underlying morality.

The differential impact of executive attention dysfunction on episodic memory in obsessive-compulsive disorder patients with checking symptoms vs. those with washing symptoms

Neuropsychological studies of obsessive-compulsive disorder (OCD) have pointed to memory and attention deficits among its sufferers, but these reports have largely ignored the possibility that cognitive disturbances may vary across OCD clinical subtypes, or that their interactions may differ between subtypes. The purpose of the present study was to determine whether "checkers" and "washers" demonstrate differences in their memory and executive attention function. Fifty-three outpatients with primary DSM-IV diagnosis of OCD with typical checking (n=27) or washing (n=26) rituals participated in the study. Patients were administered the Wechsler Memory Scale-Revised and a comprehensive neuropsychological battery to assess executive attention function. Various neuropsychological tests were then subjected to factor analysis. Neuropsychological test results and obtained factor scores were compared between "washers" and "checkers". Effects of these factor scores on memory by OCD subtypes were examined. No significant difference in terms of demographic and clinical variables was found between the two groups. Checkers displayed performance deficits on Stroop test, Trail Making Test, GO/NO GO test (commission errors) and category fluency. Three factors, inhibition, cognitive flexibility, and multi-tasking, were obtained. Statistically significant differences were observed between the two groups on the inhibition and the cognitive flexibility scores, but not on the general memory or the multi-tasking score. There was a statistically significant interaction between groups and the inhibition score. Only among "checkers", a significant correlation was noted between the inhibition factor and the general memory, while no such correlation was observed among "washers". Among "checkers", poor general memory was related to inhibition deficits.

Clinical and empirical applications of the Rey–Osterrieth Complex Figure Test

The Rey-Osterrieth Complex Figure Test (ROCF), which was developed by Rey in 1941 and standardized by Osterrieth in 1944, is a widely used neuropsychological test for the evaluation of visuospatial constructional ability and visual memory. Recently, the ROCF has been a useful tool for measuring executive function that is mediated by the prefrontal lobe. The ROCF consists of three test conditions: Copy, Immediate Recall and Delayed Recall. At the first step, subjects are given the ROCF stimulus card, and then asked to draw the same figure. Subsequently, they are instructed to draw what they remembered. Then, after a delay of 30 min, they are required to draw the same figure once again. The anticipated results vary according to the scoring system used, but commonly include scores related to location, accuracy and organization. Each condition of the ROCF takes 10 min to complete and the overall time of completion is about 30 min.

Neuropsychologic characteristics of children with attention-deficit hyperactivity disorder (ADHD), learning disorder, and tic disorder on the Rey-Osterreith Complex Figure

This study examined the performance of Korean children diagnosed with attention-deficit hyperactivity disorder (ADHD), learning disorder, ADHD with learning disorder, and tic disorder on the Rey-Osterreith Complex Figure. The clinical group consisted of 57 children between the ages of 6 and 13 years (15 with ADHD, 13 with learning disorder, 15 with ADHD + learning disorder, and 15 with tic disorder), and the control group included 20 children recruited from an elementary school. Rey-Osterreith Complex Figure productions were scored according to the Developmental Scoring System. The children in the control group showed a clear developmental trend--organization score increasing with age--that was similar to the performance of American children. No such age-related effect was found in the three clinical groups. The organization scores of the children with ADHD were lower than those of other groups, suggesting an organizational deficit in ADHD. Performance on the immediate recall condition was poorest in the tic disorder and ADHD + learning disorder groups, suggesting the presence of nonverbal memory problems in those groups.

Emotions, behaviours and mood changes in stroke

The brain mediates and integrates all cognitive activities, emotional experiences and finally behaviours. Stroke is undoubtedly a privileged disease for human behavioural studies, because of its high incidence. Recent advances in high-resolution magnetic resonance imaging techniques and functional neuroimaging allow both the precise localization of lesions and on-line visualization of the activity of cerebral areas and networks. Nevertheless, the neuropsychiatry of stroke remains uncertain in its relationship with brain dysfunction. Clinical studies on registry populations, single case studies, and functional neuroimaging data provide interesting findings, but differences in methods and great individual intervariability still prevent a complete understanding of emotional perception and behavioural responses in stroke. We adopted an anatomical-functional model as an operational framework in order to systematize the recent literature on emotional, behavioural and mood changes after stroke. The dysfunction of the areas subserving fundamental and executive functions induces behavioural and affective changes (such as depression, anxiety, apathy) that reflect the dysfunction of the whole system. Conversely, lesions in the system of instrumental functions induce signature syndromes (aphasia, anosognosia). At any delay from stroke, the diagnosis and treatment of mood and behavioural changes are a priority for clinicians and healthcare professionals to improve the quality of life of patients.

Strategic processing and episodic memory impairment in obsessive compulsive disorder

There is evidence that nonverbal memory problems in obsessive compulsive disorder (OCD) are mediated by impaired strategic processing. Although many studies have found verbal memory to be normal in OCD, these studies did not use tests designed to stress organizational strategies. This study examined verbal and nonverbal memory performance in 33 OCD patients and 30 normal control participants with the Rey-Osterrieth Complex Figure Test and the California Verbal Learning Test. OCD patients were impaired on verbal and nonverbal measures of organizational strategy and free recall. Multiple regression modeling indicated that free recall problems in OCD were mediated by impaired organizational strategies used during learning trials. Therefore, verbal and nonverbal episodic memory deficits in OCD are affected by impaired strategic processing. Results are consistent with neurobiological models proposing frontal-striatal system dysfunction in OCD.

Organizational strategies mediate nonverbal memory impairment in obsessive-compulsive disorder

BACKGROUND

Previous neuropsychological studies of obsessive-compulsive disorder (OCD) have indicated impaired executive functioning and nonverbal memory. The extent to which impaired executive functioning impacts nonverbal memory has not been established. The current study investigated the mediating effects of organizational strategies used when copying a figure on subsequent nonverbal memory for that figure.

METHODS

We examined neuropsychological performance in 20 unmedicated subjects with OCD and 20 matched normal control subjects. Subjects were administered the Rey-Osterrieth Complex Figure Test (RCFT) and neuropsychological tests assessing various aspects of executive function.

RESULTS

OCD subjects differed significantly from healthy control subjects in the organizational strategies used to copy the RCFT figure, and they recalled significantly less information on both immediate and delayed testing. Multiple regression analyses indicated that group differences in immediate percent recall were significantly mediated by copy organizational strategies. Further exploratory analyses indicated that organizational problems in OCD may be related to difficulties shifting mental and/or spatial set.

CONCLUSIONS

Immediate nonverbal memory problems in OCD subjects were mediated by impaired organizational strategies used during the initial copy of the RCFT figure. Thus, the primary deficit was one affecting executive function, which then had a secondary effect on immediate memory. These findings are consistent with current theories proposing frontal-striatal system dysfunction in OCD.

An akinetic-rigid syndrome, depression, and stereotypies in a young man

A young man is presented who developed an akinetic-rigid syndrome shortly after a minor illness. Rituals and stereoptypies were prominent. At its most severe he was unable to feed himself. There was no response to L-dopa/cardopa treatment. A course of ECT was followed by a marked improvement in his condition. Attempts to stop ECT for more than a week have led to recurrence of his bradykinesia.