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Gronewold J, Jokisch M, Schramm S, Himpfen H, Ginster T, Tenhagen I, Doeppner TR, Jockwitz C, Miller T, Lehmann N, Moebus S, Jöckel KH, Erbel R, Caspers S, Hermann DM. Association of regional white matter hyperintensities with hypertension and cognition in the population-based 1000BRAINS study. Eur J Neurol 2023; 30:1174-1190. [PMID: 36702775 DOI: 10.1111/ene.15716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/05/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND White matter hyperintensities of presumed vascular origin (WMH) are frequent in cerebral magnetic resonance imaging of older people. They are promoted by vascular risk factors, especially hypertension, and are associated with cognitive deficits at the group level. It has been suggested that not only the severity, but also the location, of lesions might critically influence cognitive deficits and represent different pathologies. METHODS In 560 participants (65.2 ± 7.5 years, 51.4% males) of the population-based 1000BRAINS study, we analyzed the association of regional WMH using Fazekas scoring separately for cerebral lobes, with hypertension and cognition. RESULTS WMH most often affected the frontal lobe (83.7% score >0), followed by the parietal (75.8%), temporal (32.7%), and occipital lobe (7.3%). Higher Fazekas scores in the frontal, parietal, and temporal lobe were associated with higher blood pressure and antihypertensive treatment in unadjusted ordinal regression models and in models adjusted for age, sex, and vascular risk factors (e.g., age- and sex-adjusted odds ratio = 1.14, 95% confidence interval = 1.03-1.25 for the association of frontal lobe WMH Fazekas score with systolic blood pressure [SBP] [per 10 mm Hg]; 1.13 [1.02-1.23] for the association of parietal lobe score with SBP; 1.72 [1.19-2.48] for the association of temporal lobe score with antihypertensive medications). In linear regressions, higher frontal lobe scores were associated with lower performance in executive function and non-verbal memory, and higher parietal lobe scores were associated with lower performance in executive function, verbal-, and non-verbal memory. CONCLUSIONS Hypertension promotes WMH in the frontal, parietal, and temporal lobe. WMH in the frontal and parietal lobe are associated with reduced executive function and memory.
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Affiliation(s)
- Janine Gronewold
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Martha Jokisch
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Sara Schramm
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Heiko Himpfen
- Department of Cardiology, Gastroenterology and Intensive-Care Medicine, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Theresa Ginster
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Isabell Tenhagen
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | | | - Christiane Jockwitz
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany.,Institute for Anatomy I, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Tatiana Miller
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany.,Institute for Anatomy I, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Nils Lehmann
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Susanne Moebus
- Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Svenja Caspers
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany.,Institute for Anatomy I, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Dirk M Hermann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
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Taniguchi A, Shindo A, Tabei KI, Onodera O, Ando Y, Urabe T, Kimura K, Kitagawa K, Miyamoto Y, Takegami M, Ihara M, Mizuta I, Mizuno T, Tomimoto H. Imaging Characteristics for Predicting Cognitive Impairment in Patients With Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy. Front Aging Neurosci 2022; 14:876437. [PMID: 35754959 PMCID: PMC9226637 DOI: 10.3389/fnagi.2022.876437] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives Patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) show various clinical symptoms, including migraine, recurrent stroke, and cognitive impairment. We investigated the associations between magnetic resonance imaging (MRI) markers of small vessel disease and neuropsychological tests and identified the MRI characteristics for predicting cognitive impairment in patients with CADASIL. Methods Subjects included 60 CADASIL patients diagnosed with genetic tests and registered in the Japanese CADASIL REDCap database between June 2016 and December 2020. Patient information including clinical data, modified Rankin Scale (mRS); MRI findings of small vessel disease including periventricular and deep white matter lesions (WML), lacunar infarcts, and cerebral microbleeds (CMBs); and neuropsychological tests, including the Japanese version of the Mini-Mental State Examination (MMSE), the Japanese version of the Montreal Cognitive Assessment (MoCA-J), and the Frontal Assessment Battery (FAB), were evaluated. Results Data from 44 CADASIL patients were eligible for this study, compared between patients with and without dementia. Regarding the neuroimaging findings, the Fazekas score of periventricular and deep WML was higher in patients with dementia (periventricular, p = 0.003; deep, p = 0.009). The number of lacunar infarcts was higher in patients with dementia (p = 0.001). The standardized partial regression coefficient (SPRC) in MoCA-J was 0.826 (95% CI, 0.723-0.942; p = 0.005) for the number of CMBs. The SPRC in MMSE was 0.826 (95% CI, 0.719-0.949; p = 0.007) for the number of CMBs. The SPRC for FAB decreased significantly to 0.728 (95% CI, 0.551-0.960; p = 0.024) for the number of lacunar infarcts. Receiver operating characteristic (ROC) curves for dementia showed that in the number of lacunar infarcts, a cut-off score of 5.5 showed 90.9% sensitivity and 61.1% specificity. For the number of CMBs, a cut-off score of 18.5 showed 45.5% sensitivity and 100% specificity. Conclusion The characteristic MRI findings were that CADASIL patients with dementia had severe WML, both periventricular and deep, and a larger number of lacunar infarcts than those without dementia. The risk of dementia may be associated with ≥ 6 lacunar infarcts, ≥19 CMBs, or a Fazekas scale score of 3 in periventricular and deep WML.
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Affiliation(s)
- Akira Taniguchi
- Department of Neurology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiro Shindo
- Department of Neurology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ken-ichi Tabei
- Department of Neurology, Mie University Graduate School of Medicine, Tsu, Japan
- School of Industrial Technology, Advanced Institute of Industrial Technology, Tokyo Metropolitan Public University Corporation, Tokyo, Japan
| | - Osamu Onodera
- Department of Neurology, Clinical Neuroscience Branch, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Amyloidosis Research, Nagasaki International University, Nagasaki, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoshihiro Miyamoto
- Open Innovation Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ikuko Mizuta
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidekazu Tomimoto
- Department of Neurology, Mie University Graduate School of Medicine, Tsu, Japan
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Yamasaki T, Ikawa F, Hidaka T, Kuwabara M, Matsuda S, Ozono I, Chiku M, Kitamura N, Hamano T, Akishita M, Yamaguchi S, Tomimoto H, Suzuki M. Prevalence and risk factors for brain white matter changes in young and middle-aged participants with Brain Dock (brain screening): a registry database study and literature review. Aging (Albany NY) 2021; 13:9496-9509. [PMID: 33820872 PMCID: PMC8064194 DOI: 10.18632/aging.202933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
This study aimed to determine the prevalence and risk factors for brain white matter changes in normal young and middle-aged participants who underwent Brain Dock (brain screening). We analyzed 5,000 consecutive healthy participants from the Brain Dock registry between August to December 2018. Age, sex, body mass index (BMI), medical history, deep subcortical white matter high intensity (DSWMH), periventricular high intensity (PVH), and enlargement of perivascular space (EPVS) were investigated in relation to age. The prevalence of DSWMH, PVH, and EPVS were 35.3%, 14.0%, and 17.8%, respectively. Multivariate logistic regression analyses for brain white matter changes were conducted. The significant risk factors in participants aged < 50 years were: age (OR:1.09, 95% CI:1.07-1.12), the female sex (1.29, 1.03-1.60), BMI obesity (1.86, 1.12-3.08), and hypertension (1.67, 1.18-2.35) for DSWMH; age (1.08, 1.04-1.13) and the female sex (1.56, 1.03-2.36) for PVH; and age (1.07, 1.05-1.10) and the female sex (0.77, 0.60-1.00) for EPVS. In conclusion, age was consistently identified as a significant risk factor in young and middle-aged participants. Some risk factors for brain white matter changes were identified even in young and middle-aged participants in this study. Further longitudinal studies should be done in the future.
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Affiliation(s)
- Tomohiro Yamasaki
- Postgraduate Clinical Training Center, Shimane University Hospital, Shimane, Japan
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Masaaki Chiku
- Department of Cardiovascular Medicine, Medical Check Studio Tokyo Ginza Clinic, Tokyo, Japan
| | - Naoyuki Kitamura
- Department of Diagnostic Radiology, Kasumi Clinic, Hiroshima, Japan
| | | | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Hidekazu Tomimoto
- Department of Neurology, Mie University Graduate School of Medicine, Mie, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Saeki S, Ogata H, Okubo T, Takahashi K, Hoshuyama T. Impact of factors indicating a poor prognosis on stroke rehabilitation effectiveness. Clin Rehabil 2016. [DOI: 10.1177/026921559300700202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examines the impact of factors indicating a poor prognosis on rehabilitation effectiveness of 124 first stroke patients admitted to a comprehensive rehabilitation unit in Kitakyushu, Japan. A multiple regression model, employing a forced entry of variables guided by prior studies on these factors, found four significant factors. Lack of motivation, urinary incontinence, each 10 years of age, and each day's delay from stroke onset to the commencement of rehabilitation reduced the rehabilitation effectiveness by 20%, 15%, 4%, and 0.1% respectively. The values of beta-coefficients showed that onset-rehabilitation delay and lack of motivation were relatively important in our model. These findings are consistent with clinical impressions and provide useful information for planning stroke rehabilitation programmes.
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Affiliation(s)
- Satoru Saeki
- Department of Rehabilitation Medicine, University of Occupational and Environmental Health
| | - Hajime Ogata
- Department of Rehabilitation Medicine, University of Occupational and Environmental Health
| | - Toshiteru Okubo
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Japan
| | - Ken Takahashi
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Japan
| | - Tsutomu Hoshuyama
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Japan
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Micieli G, Bosone D, Cavallini A, Bono G, Uggetti C, Rossi F, Nappi G. Carotid Plaques and Multiple Brain Infarctions. J Neuroimaging 2016. [DOI: 10.1111/jon199334220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abe A, Nishiyama Y, Harada-Abe M, Okubo S, Ueda M, Mishina M, Katayama Y. Relative risk values of age, acrolein, IL-6 and CRP as markers of periventricular hyperintensities: a cross-sectional study. BMJ Open 2014; 4:e005598. [PMID: 25232562 PMCID: PMC4139621 DOI: 10.1136/bmjopen-2014-005598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Brain white matter hyperintensities can be divided into periventricular hyperintensity (PVH) and deep-and-subcortical white matter hyperintensity (DSWMH); the former contributes more to cognitive dysfunction and infarction risk. We conducted the present investigation to define the relationship between PVH and DSWMH. DESIGN Cross-sectional study. SETTING University hospital. PARTICIPANTS We prospectively enrolled 228 healthy Japanese volunteers with relative risk values (RRVs) >0.5. PRIMARY OUTCOME MEASURES We investigated whether it is possible to use the RRV to predict PVH and DSWMH. RESULTS Among 228 volunteers, 103 (45.1%) and 157 (68.8%) exhibited PVH and DSWMH, respectively. Age, body mass index and PVH were significant independent determinants of RRV. A significant OR for PVH was noted in the highest RRV tertile compared with the lowest, after adjusting for potential confounding factors. A significant OR for high predicted PVH risk was found for RRV levels as well. CONCLUSIONS Elevated RRV levels were significantly associated with increased predicted PVH, suggesting that measuring the plasma protein-conjugated acrolein, interleukin 6 and C reactive protein levels may be useful for identifying Japanese at high risk for PVH.
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Impaired executive function following ischemic stroke in the rat medial prefrontal cortex. Behav Brain Res 2014; 258:106-11. [DOI: 10.1016/j.bbr.2013.10.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/06/2013] [Accepted: 10/11/2013] [Indexed: 11/23/2022]
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Barbov I, Arsova S, Taravari A, Petrova V. Do Silent Brain Infarctions Predict the Development of Dementia After First Ischemic Stroke? Open Access Maced J Med Sci 2013. [DOI: 10.3889/oamjms.2013.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Silent brain infarctions (SBI) are common findings in advanced age, but their relationship to dementia is still uncertain.Aim: The present study was designed to evaluate whether SBI predict the development of dementia after first clinical ischemic stroke.Methods: We blindly studied admission CT scans of 102 consecutive nondemented patients presenting with ischemic stroke that clinically was their first stroke episode. SBI were defined as CT evidence of infarcts not compatible with the acute event. The patients were subsequently followed for their mental state for 2 years. Survival analysis, wherein onset of dementia was the end point, was performed on the total sample population and conducted separately on those with and without SBI at admission.Results: Dementia developed in 33 patients (32.3%), including 17 of the 37 (45.9%) with SBI and 16 of the 65 (24.6%) without SBI. Thus, dementia was strong related to SBI.Conclusion: Elderly people with silent brain infarcts and stroke have an increased risk of dementia and a steeper decline in cognitive function than those without such lesions.
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Kobayashi A, Iguchi M, Shimizu S, Uchiyama S. Silent Cerebral Infarcts and Cerebral White Matter Lesions in Patients with Nonvalvular Atrial Fibrillation. J Stroke Cerebrovasc Dis 2012; 21:310-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2010.09.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/31/2010] [Accepted: 09/03/2010] [Indexed: 10/18/2022] Open
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Kim SW, Kim SB, Lee SY, Koh SE, Lee JM, Lee JY. Motor Evoked Potentials and Somatosensory Evoked Potentials of Upper and Lower Extremities for Prediction of Functional Recovery in Stroke. BRAIN & NEUROREHABILITATION 2012. [DOI: 10.12786/bn.2012.5.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Se-Won Kim
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Seung-Beom Kim
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Su-Young Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Seong-Eun Koh
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Jong-Min Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Joo-Young Lee
- Department of Rehabilitation Medicine, Kyounghee Neulfureun Geriatrics Hospital, Korea
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Obara K, Meyer JS, Muramatsu K, Mortel KF. Lacune-associated cerebral hypoperfusion correlates with cognitive testing. J Stroke Cerebrovasc Dis 2010; 4:121-9. [PMID: 26487613 DOI: 10.1016/s1052-3057(10)80120-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The hypothesis was tested among 83 patients with multiple lacunar infarctions that cerebral hypoperfusion will correlate with cognitive impairments. Patients were subdivided according to Cognitive Capacity Screening Examination (CCSE) scores into a cognitively impaired group (Group D, n = 40; mean age, 68.2 years) with CCSE scores between 6 and 25 (mean, 19.9) and a cognitively intact group (Group I, n = 43; mean age, 66.0) with normal scores (mean, 29.4). Gray and white matter tissue densities were measured by plain computed tomography (CT), and their compartmental perfusions were estimated during stable xenon inhalation. Eighty infarcts in basal ganglia and white matter were detected in Group D and 62 in Group I. Cognitive impairments correlated with (a) multiplicity and bilaterality of lacunes; (b) hypertension, diabetes mellitus, and multiplicity of risk factors for stroke; (c) hypoperfusion of white and gray matter, but particularly of frontal white matter; (d) leuko-araiosis; (e) aging; and (f) lower education. The conclusion was that hypertension and diabetes mellitus are potent risk factors for cerebral small vessel disease or arteriolosclerosis ultimately resulting in lacunar infarcts, leuko-araiosis, white matter hypoperfusion, and impaired cognitive test performance.
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Affiliation(s)
- K Obara
- From the Cerebrovascular Research Laboratories, Department of Veterans Affairs Medical Center, and Department of Neurology, Baylor College of Medicine, Houston, TX, U.S.A
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Nitkunan A, Charlton RA, Barrick TR, McIntyre DJO, Howe FA, Markus HS. Reduced N-acetylaspartate is consistent with axonal dysfunction in cerebral small vessel disease. NMR IN BIOMEDICINE 2009; 22:285-291. [PMID: 19009567 DOI: 10.1002/nbm.1322] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Cerebral small vessel disease (SVD) is an important cause of cognitive impairment, but the pathophysiological mechanisms remain unclear. We used (1)H MRS to investigate brain metabolic differences between patients with SVD and controls and correlated this with cognition. METHODS 35 patients with SVD (lacunar stroke and radiological evidence of confluent leukoaraiosis) and 35 controls underwent multi-voxel spectroscopic imaging of white matter to obtain absolute metabolite concentrations of N-acetylaspartate (NAA), total creatines, total cholines, myo-inositol, and lactate. A range of cognitive tests was performed on patients with SVD, and composite scores were calculated. RESULTS Scans of sufficient quality for data analysis were available in 29 cases and 35 controls. NAA was significantly reduced in patients compared with controls (lower by 7.27%, P = 0.004). However, when lesion load within each individual voxel (mean 22% in SVD vs 5% in controls, P < 0.001) was added as a covariate, these differences were no longer significant, suggesting that the metabolite differences arose primarily from differences in lesioned tissue. In patients with SVD, there was no correlation between cognitive scores and any brain metabolite. No lactate, an indicator of anaerobic metabolism, was detected. CONCLUSIONS The most consistent change in SVD is a reduction in NAA, a marker of neuronal integrity. The lack of correlation with cognition does not support the use of MRS as a surrogate disease marker.
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Affiliation(s)
- Arani Nitkunan
- Centre for Clinical Neuroscience, St George's, University of London, London, UK.
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Ohmine T, Miwa Y, Yao H, Yuzuriha T, Takashima Y, Uchino A, Takahashi-Yanaga F, Morimoto S, Maehara Y, Sasaguri T. Association between arterial stiffness and cerebral white matter lesions in community-dwelling elderly subjects. Hypertens Res 2008; 31:75-81. [PMID: 18360021 DOI: 10.1291/hypres.31.75] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The presence of cerebral white matter lesions (WMLs) on MRI is suggested to be a predictive factor for vascular dementia and stroke. To investigate the relationship between arterial stiffness and WMLs, we performed brain MRI to evaluate the presence of two subtypes of WML-periventricular hyperintensities (PVH) and deep white matter lesions (DWML)-and furthermore, determined the brachial-ankle pulse wave velocity (ba-PWV) as a marker of arterial stiffness in 132 elderly asymptomatic subjects (49 men and 83 women, 70.3+/-9.0 years). PVH and DWML were observed in 41 (31.0%) and 53 (40.2%) subjects, respectively. The ba-PWV values were significantly greater in subjects with PVH than in those without. DWML also tended to be associated with ba-PWV, but the correlation was not statistically significant. In multiple logistic regression analysis, age and decreased DBP were independently associated with PVH. ba-PWV was also detected as an independent factor for the appearance of PVH (adjusted odds ratio: 2.84, p=0.015) but not DWML. These results indicate that the increase in arterial stiffness contributes to the pathogenesis of PVH rather than DWML. Although further study is needed to clarify the difference between WML subtypes, our study suggests that the measurement of ba-PWV is a simple and useful tool for detecting cerebral arterial dysfunction.
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Affiliation(s)
- Takahiro Ohmine
- Department of Clinical Pharmacology, Graduate School of Medical Sciences, Kyushu University, Fuuoka, Japan
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Ishii H, Meguro K, Yamaguchi S, Ishikawa H, Yamadori A. Prevalence and cognitive performances of vascular cognitive impairment no dementia in Japan: the Osaki?Tajiri Project. Eur J Neurol 2007; 14:609-16. [PMID: 17539936 DOI: 10.1111/j.1468-1331.2007.01781.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prevalence, magnetic resonance imaging (MRI) findings, cognitive function and depression are four major aspects of vascular cognitive impairment no dementia (vascular CIND). We performed a community-based study to examine these using 497 community-residents aged 65 years or older. Vascular CIND was defined as a clinical dementia rating (CDR) 0.5 with cerebrovascular disease. Several neuropsychological tests were performed, including MMSE, Geriatric Depression Scale (GDS), and Trail Making Test (TMT). Cerebrovascular disease and white matter lesions were visually assessed using MRI. Prevalence of vascular CIND, localization of cerebrovascular disease, and the relationships amongst MRI findings, white matter lesions, cognitive impairment and depression were analyzed. The prevalence of vascular CIND was 8.5% amongst the total population, corresponding to the rate being 37.2% amongst the CDR 0.5 participants. Compared with the CDR 0, the CDR 0.5 group had more subjects with strategic cerebrovascular disease in the thalamus, etc. No effects of cerebrovascular disease on MMSE and GDS scores were found, but the CDR 0.5/strategic cerebrovascular disease group showed impaired TMT-B scores. In the CDR 0 group, only anterior periventricular hyperintensity was associated with TMT-A score independent of cerebrovascular disease. A vascular CIND population was identified, and executive dysfunction in this population is probably based on an impaired fronto-subcortical circuit.
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Affiliation(s)
- H Ishii
- Department of Geriatric Behavioral Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Baloyannis SJ. Pathological alterations of the climbing fibres of the cerebellum in vascular dementia: a Golgi and electron microscope study. J Neurol Sci 2007; 257:56-61. [PMID: 17448497 DOI: 10.1016/j.jns.2007.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The climbing fibres originating from the inferior olivary nucleus act as a powerful excitation on the Purkinje cells of the cerebellar cortex that may play a substantial role in the motor performances and the learning of new motor skills. In vascular dementia the existent vascular alterations may induce many hypoxic or ischemic phenomena, among the others, in the olivocerebellar system affecting the climbing fibres in their way to the molecular layer of the cerebellar cortex. In autopsy cases of vascular dementia, the application of silver impregnation technique and electron microscopy revealed a substantial decrease of the number of the climbing fibres in the cortex of the vermis, the flocculus and the cerebellar hemispheres. The presynaptic varicosities and the synaptic terminals of the climbing fibres on the Purkinje cell dendrites were decreased in number and moreover were characterized by a marked poverty of synaptic vesicles. The synaptic cleft was mostly abnormal and wider than 20 nm. Mitochondrial abnormalities, such as elongated mitochondria with disruption of the cristae were seen in the terminal branches of the climbing fibre arborization as well as in the presynaptic components. The blood capillaries demonstrated a considerable thickness of the basal membrane and perivascular astrocytic proliferation, whereas the tight junctions between the endothelial cells were ultrastructurally intact. We would hypothesize that the morphological and morphometric alterations of the climbing fibres of the cerebellar cortex in cases of vascular dementia might be associated with the frequently noticed difficulty in the performance of fine and skilful movements by the patients.
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Ishii H, Meguro K, Yamaguchi S, Hirayama K, Tabuchi M, Mori E, Yamadori A. Different MRI findings for normal elderly and very mild Alzheimer's disease in a community: Implications for clinical practice. Arch Gerontol Geriatr 2006; 42:59-71. [PMID: 16085324 DOI: 10.1016/j.archger.2005.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Revised: 06/06/2005] [Accepted: 06/09/2005] [Indexed: 11/28/2022]
Abstract
To investigate magnetic resonance imaging (MRI) findings of very mild dementia, 485 participants were randomly selected in a community. Three hundred and forty participants were of Clinical Dementia Rating (CDR) 0 (healthy), 113 were of CDR 0.5 (questionable dementia), and 32 were of CDR 1 and 2 (including 20 Alzheimer's disease, AD). Cortical atrophy, white matter lesion, etc., were visually assessed. We found that each part of the brain showed atrophy in older adults for CDR 0. For CDR 0.5, the relationships between MRI findings and age were weaker, and for AD, there were no such relationship. Atrophy related with dementia severity was found to be limited to the lateral and medial temporal lobes. For CDR 0.5, amygdala atrophy was the only finding indicating CDR effect but no age effect. The amygdala or anterior entorhinal atrophy is important for discriminating very mild dementia from normal elderly.
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Affiliation(s)
- Hiroshi Ishii
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
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Baloyannis SJ. The acoustic cortex in vascular dementia: a Golgi and electron microscope study. J Neurol Sci 2005; 229-230:51-5. [PMID: 15760619 DOI: 10.1016/j.jns.2004.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Morphological alterations in vascular dementia have been extensively described in the hippocampus, the cerebral cortex, the subcortical centers and the cerebellum. In the present study, we describe the morphological alterations of the acoustic cortex in five cases, which fulfilled the clinical, neuropsychological and laboratory diagnostic criteria of vascular dementia. The morphological alterations, seen in Golgi technique and electron microscopy concerned the capillaries, the dendritic arborization of the neurons, the astrocytes and the cytoarchitecture of the cortex. The neurons showed an impressive abbreviation of the dendritic fields and loss of spines. Astrocytic proliferation was seen in the cortex. The layer I showed marked decline of Cajal-Retzius cells. The majority of the synapses demonstrated changes in size and shape of the pre- and postsynaptic components and alterations of the organelles. The morphological alterations of the acoustic cortex in vascular dementia may be associated with the impairment of the verbal communication, which is not an uncommon phenomenon even in the early stages of the vascular dementia.
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Abstract
Risk of dementia increases after stroke, and poststroke dementia (PSD) is an important cause of disability in the elderly. The prevalence rates of PSD vary from 12.2% to 31.8% within 3 months to 1 year after stroke, depending on patient populations and the diagnostic criteria used in the numerous studies. Incidence rates of PSD increase with time after the stroke. Although vascular lesions and white matter changes can explain the cognitive disorders seen in stroke patients, an underlying neurodegenerative disorder may contribute to the development of PSD. Cognitive decline may pre-date the stroke and follow a progressive course after the stroke. The vascular and degenerative processes involved share common environmental and genetic risk factors. This review explains the mechanisms of dementia in stroke patients and identifies predictive factors for PSD. The following points are successively considered: (i) demographic characteristics of the patients, including age and level of education; (ii) prestroke cognitive decline; (iii) vascular risk factors, including diabetes mellitus and prior strokes; (iv) stroke characteristics, including severity and location of the vascular lesion; (v) co-morbid disorders; and (vi) abnormalities on brain imaging, including location, size and number of vascular lesions, white matter changes and cerebral atrophy. Older age, prestroke cognitive decline, stroke recurrence, hypoxic-ischaemic disorders, left-side infarcts, strategic infarcts and white matter lesions appear to be the main predictive factors of PSD. Prevention of stroke should reduce the morbidity and mortality associated with PSD. In addition, management of PSD with secondary prevention treatments could reduce occurrence of further strokes. Cholinesterase inhibitors may be beneficial not only in Alzheimer's disease associated with cerebrovascular lesions, but also for the treatment of cholinergic dysfunction arising from pure vascular dementia. Better knowledge of the risk factors for PSD, including environmental and genetic factors, should increase the effectiveness of preventive strategies in patients with this condition.
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Yamaguchi S, Matsubara M, Kobayashi S. Electrophysiological assessment of Choto-san treatment for stroke patients with mild cognitive impairments. Geriatr Gerontol Int 2004. [DOI: 10.1111/j.1447-0594.2004.00174.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yamaguchi S, Matsubara M, Kobayashi S. Event-related brain potential changes after Choto-san administration in stroke patients with mild cognitive impairments. Psychopharmacology (Berl) 2004; 171:241-9. [PMID: 14615873 DOI: 10.1007/s00213-003-1593-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2002] [Accepted: 07/10/2003] [Indexed: 10/26/2022]
Abstract
RATIONALE Few drugs have been reported to be effective for the treatment of vascular dementia. Choto-san is a herbal medicine expected to be effective in this condition, but it is unclear how this drug modulates brain activities and cognitive functions. P3 event-related brain potentials (ERP) provide reliable electrophysiological indices for some aspects of cognitive functions. OBJECTIVES We measured P3 ERP to assess the effect of Choto-san administration on stroke patients with mild cognitive impairments. METHODS Choto-san was given for 12 weeks to ten chronic stroke patients. P3 ERP were recorded before and after drug administration in a modified auditory oddball paradigm including occasional novel sounds using a high-density array EEG recording system. The reproducibility of ERP was also assessed in other ten stroke patients with a 12-week interval. Cognitive functions were assessed with the Mini Mental State Examination (MMSE) and verbal fluency test. RESULTS Twelve-week administration of Choto-san significantly improved MMSE and verbal fluency test scores. The reproducibility of P3 latency and amplitude to target and novel sounds was excellent. P3 latency to target sounds was shortened in association with reduced reaction time to the sounds after drug administration. Furthermore, P3 amplitude to novel sounds was enlarged and its topography shifted from central to frontal sites. CONCLUSIONS These results indicate that Choto-san improves electrophysiological indices related to attention and decision making, in addition to neuropsychological test scores in stroke patients with mild cognitive impairments.
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Affiliation(s)
- Shuhei Yamaguchi
- Department of Internal Medicine III, Shimane Medical University, 89-1 Enya-cho, 693-8501 Izumo, Japan.
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22
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Yoshida R, Ito Y, Hatta M, Otomo E. [Cerebrovascular disease in very old people]. Nihon Ronen Igakkai Zasshi 2003; 40:120-3. [PMID: 12708042 DOI: 10.3143/geriatrics.40.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Yang DW, Kim BS, Park JK, Kim SY, Kim EN, Sohn HS. Analysis of cerebral blood flow of subcortical vascular dementia with single photon emission computed tomography: adaptation of statistical parametric mapping. J Neurol Sci 2002; 203-204:199-205. [PMID: 12417384 DOI: 10.1016/s0022-510x(02)00291-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Subcortical vascular dementia (VaD) is a relatively homogeneous subtype of VaD, but the mechanisms of cognitive dysfunction of subcortical VaD are not fully understood. This study investigates the changes of cerebral blood flow (CBF) in patients with subcortical VaD and the contribution of the white matter hyperintensity (WMHI) and clinical severity to CBF changes. METHODS 99mTc-ethyl cysteinate dimer single photon emission computed tomography (SPECT) was performed to measure the regional CBF and statistical parametric mapping SPM99 software was applied to automated and objective analysis of the SPECT image data. Twenty-three patients (12 male, 11 female) with mild to moderate dementia who met both the criteria of the DSM-IV and probable and possible NINDS-AIREN for VaD and had subcortical white matter changes and lacunar infarctions in brain MRI were evaluated against 17 normal control subjects (7 male, 10 female). The severity of the WMHI was measured by the semi-quantitative scale method proposed by Mäntyla. The Clinical Dementia Rating scale measured the severity of dementia. RESULTS SPM analysis of the SPECT image reveals significantly reduced regional CBF in the right thalamus, left caudate nucleus, cingulate, bilateral superior temporal, and left ventral subcallosal gyri in subcortical VaD patients compared to the normal controls (corrected P<0.001). Of four WMHIs, only the deep WMHI was associated with the small CBF reduction in the left superior temporal gyrus (uncorrected P<0.01). The reduction of the CBF according to the severity of dementia was noted in the anterior and posterior association areas (uncorrected P<0.01). CONCLUSIONS Our study suggests that cognitive dysfunction of subcortical VaD may be related to the reduction of the CBF in the brain areas mentioned, which are probably not associated with the severity of periventricular WMHI and dementia.
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Affiliation(s)
- Dong-Won Yang
- Department of Neurology, College of Medicine, The Catholic University of Korea, South Korea
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Abstract
Age-related white matter changes (WMC) are a frequent finding in CT/MRI of older subjects. The role of WMC in cognitive impairment has been studied in community-dwelling and healthy old people, subjects with vascular risk factors, stroke patients, depressed and demented subjects. Although there are several negative studies, the majority of the evidence points towards an association between WMC and cognitive impairment. Speed of mental processes, attention, concentration, executive functions and visual spatial skills are the cognitive domains more commonly affected. The methodological problems of the negative studies are discussed, a number of unsolved issues are raised stressing the need for longitudinal studies of WMC with a adequate inception cohort.
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Affiliation(s)
- José M Ferro
- Centro de Estudos Egas Moniz, Serviço de Neurologia, Hospital Santa Maria, 1649-035 Lisbon, Portugal.
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Abstract
The risk of dementia is increased in stroke patients. Dementia syndromes associated with cerebrovascular diseases were commonly recognized as an immediate consequence of stroke. However, more and more data suggest that degenerative pathology and white matter changes (WMC) may play a role in the development of dementia in stroke patients. The aim of this paper was to review the literature concerning the neuroimaging predictors of dementia in stroke patients. From the literature data, it appears that although vascular lesions alone may lead to dementia, in stroke patients, no clear association between stroke location and size has yet been identified, even if the role of the left hemisphere has been suggested. The influence of silent infarcts remains undetermined while more and more data suggest that global cerebral atrophy and WMC are predictive factors of post-stroke dementia (PSD). The influence of medial temporal lobe atrophy on the risk of PSD has until now never been evaluated.
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Affiliation(s)
- Hilde Hénon
- Stroke Department, Roger Salengro Hospital, Lille, France F-59037.
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Hsu YY, Du AT, Schuff N, Weiner MW. Magnetic resonance imaging and magnetic resonance spectroscopy in dementias. J Geriatr Psychiatry Neurol 2001; 14:145-66. [PMID: 11563438 PMCID: PMC1857299 DOI: 10.1177/089198870101400308] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews recent studies of magnetic resonance imaging and magnetic resonance spectroscopy in dementia, including Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, idiopathic Parkinson's disease, Huntington's disease, and vascular dementia. Magnetic resonance imaging and magnetic resonance spectroscopy can detect structural alteration and biochemical abnormalities in the brain of demented subjects and may help in the differential diagnosis and early detection of affected individuals, monitoring disease progression, and evaluation of therapeutic effect.
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Affiliation(s)
- Y Y Hsu
- Magnetic Resonance Unit, Department of Veterans Affairs Medical Center, San Francisco 94121, USA
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Fein G, Di Sclafani V, Tanabe J, Cardenas V, Weiner MW, Jagust WJ, Reed BR, Norman D, Schuff N, Kusdra L, Greenfield T, Chui H. Hippocampal and cortical atrophy predict dementia in subcortical ischemic vascular disease. Neurology 2000; 55:1626-35. [PMID: 11113215 PMCID: PMC2733356 DOI: 10.1212/wnl.55.11.1626] [Citation(s) in RCA: 275] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The cause of dementia in subcortical ischemic vascular disease (SIVD) is controversial. OBJECTIVES To determine whether cognitive impairment in SIVD 1) correlates with measures of ischemic brain injury or brain atrophy, and/or 2) is due to concomitant AD. METHODS Volumetric MRI of the brain was performed in 1) elderly subjects with lacunes (L) and a spectrum of cognitive impairment-normal cognition (NC+L, n = 32), mild cognitive impairment (CI+L, n = 26), and dementia (D+L, n = 29); 2) a comparison group with probable AD (n = 28); and 3) a control group with normal cognition and no lacunes (NC). The authors examined the relationship between the severity of cognitive impairment and 1) volume, number, and location of lacunes; 2) volume of white matter signal hyperintensities (WMSH); and 3) measures of brain atrophy (i. e., hippocampal, cortical gray matter, and CSF volumes). RESULTS Among the three lacune groups, severity of cognitive impairment correlated with atrophy of the hippocampus and cortical gray matter, but not with any lacune measure. Although hippocampal atrophy was the best predictor of severity of cognitive impairment, there was evidence for a second, partially independent, atrophic process associated with ventricular dilation, cortical gray matter atrophy, and increase in WMSH. Eight autopsied SIVD cases showed variable severity of ischemic and neurofibrillary degeneration in the hippocampus, but no significant AD pathology in neocortex. The probable AD group gave evidence of only one atrophic process, reflected in the severity of hippocampal atrophy. Comparison of regional neocortical gray matter volumes showed sparing of the primary motor and visual cortices in the probable AD group, but relatively uniform atrophy in the D+L group. CONCLUSIONS Dementia in SIVD, as in AD, correlates best with hippocampal and cortical atrophy, rather than any measure of lacunes. In SIVD, unlike AD, there is evidence for partial independence between these two atrophic processes. Hippocampal atrophy may result from a mixture of ischemic and degenerative pathologies. The cause of diffuse cortical atrophy is not known, but may be partially indexed by the severity of WMSH.
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Affiliation(s)
- G Fein
- Neurobehavioral Research, Inc., San Francisco, CA, USA
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Sabatini T, Frisoni GB, Barbisoni P, Bellelli G, Rozzini R, Trabucchi M. Atrial fibrillation and cognitive disorders in older people. J Am Geriatr Soc 2000; 48:387-90. [PMID: 10798464 DOI: 10.1111/j.1532-5415.2000.tb04695.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To find a correlation between chronic nonrheumatic atrial fibrillation (CNRAF) and cognitive impairment in a group of older, nondemented patients. SETTING Acute Care Unit for the Elderly, Poliambulanza Hospital, Brescia (Italy). METHODS Two hundred fifty-five hospital in-patients older than 70 years (42 with CNRAF and 213 controls with normal sinus rhythm) were assessed by complete clinical history, physical examination, ECG, serum albumin levels, APACHE II score, mental status (Mini-Mental State Exam [MMSE] and Geriatric Depression Score [GDS]), functional status (Barthel Index and instrumental activities of daily living [IADL]), number of prescribed drugs, and comorbidity (Charlson Index). RESULTS The group of patients with CNRAF had MMSE scores significantly lower than that of the reference group with normal sinus rhythm. Chronic nonrheumatic atrial fibrillation retained an independent relation to cognitive impairment also after adjusting for those variables associated with mental decline in univariate models (GDS, IADL, and APACHE II scores). CONCLUSIONS The results of this study support the relationship between nonrheumatic atrial fibrillation and impaired cognitive function. Independent of etiopathogenetic mechanisms (thromboembolic or hemodynamic hypotheses), prevention of cognitive impairment in older persons should take into account the treatment of atrial fibrillation and its consequences.
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Affiliation(s)
- T Sabatini
- Acute Care Unit for the Elderly, Poliambulanza Hospital, Brescia, Italy
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Yamaguchi S, Tsuchiya H, Yamagata S, Toyoda G, Kobayashi S. Event-related brain potentials in response to novel sounds in dementia. Clin Neurophysiol 2000; 111:195-203. [PMID: 10680554 DOI: 10.1016/s1388-2457(99)00228-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Non-target, deviant stimuli generate an earlier latency, front-central novelty P3, whereas correctly detected task-relevant stimuli generate a parietal maximal target P3. We examined whether the P3 component to novel stimuli is affected by dementing processes, and is therefore useful for distinguishing Alzheimer's type dementia (AD) from vascular dementia (VD). METHODS We recorded ERPs to task-relevant stimuli (target P3) and novel task-irrelevant stimuli (novelty P3) in an auditory oddball task in AD (n = 16), VD (n = 16), and age-matched controls (n = 18). The amplitude, latency, and scalp topography of target and novelty P3 were compared among 3 groups using ANOVA. The relationship between P3 measures and intelligence scores were evaluated by correlation analysis. RESULTS The amplitude, latency and scalp topography of the target P3 were comparably affected by both AD and VD. However, the amplitude of the novelty P3 was markedly reduced in VD, but not in AD, and the scalp topographics were different in the 3 groups. The amplitude was maximal at frontal sites in controls, at central sites in AD, and at parietal sites in VD. The target P3 latency was prolonged in both AD and VD, whereas the novelty P3 latency was only prolonged in VD. AD was discriminated satisfactorily from VD by using the novelty amplitude at Cz and the ratio of the amplitudes at Fz and Pz as independent variables. CONCLUSIONS These results suggest that the response to novel stimuli is differentially affected by dementia with degenerative and vascular etiology.
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Affiliation(s)
- S Yamaguchi
- Department of Internal Medicine III, Shimane Medical University, Izumo, Japan.
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Hanyu H, Asano T, Sakurai H, Iwamoto T, Takasaki M, Shindo H, Abe K. Magnetization transfer ratio in cerebral white matter lesions of Binswanger's disease. J Neurol Sci 1999; 166:85-90. [PMID: 10475100 DOI: 10.1016/s0022-510x(99)00122-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We measured the magnetization transfer (MT) ratios in white matter lesions of Binswanger's disease (BD) and compared them with BD and with similar-appearing changes in non-demented elderly subjects and cerebral infarction. Four subject groups were studied: 30 patients with BD and periventricular hyperintensity (PVH) on MRI, 29 patients with ischemic cerebrovascular event with PVH but no dementia, 17 patients with old cerebral infarction, and 26 elderly control subjects. MT ratios were calculated for areas of PVH in BD and non-demented subjects, of infarction, and of normal-appearing white matter in controls. The decrease in MT ratios for areas in PVH of non-demented subjects and BD and in infarction compared with normal white matter in controls was 12, 20, and 35%, respectively. The MT ratio in PVH of BD was significantly lower than that in PVH of non-demented subjects, but not to the levels seen in areas of infarction. There was a significant high correlation between the Mini-Mental State Examination score and MT ratio for area of PVH (r = 0.790). MT ratio distinguishes PVH in BD patients from those in non-demented subjects, suggesting underlying histopathological differences. Tissue damage in white matter lesions of BD may be more severe than that in non-demented subjects, but not as much as with complete infarction.
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Affiliation(s)
- H Hanyu
- Department of Geriatric Medicine, Tokyo Medical University, Japan
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Pasquier F, Leys D, Scheltens P. The influence of coincidental vascular pathology on symptomatology and course of Alzheimer's disease. JOURNAL OF NEURAL TRANSMISSION. SUPPLEMENTUM 1998; 54:117-27. [PMID: 9850920 DOI: 10.1007/978-3-7091-7508-8_11] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The aim of this review is to determine the influence of coincidental cerebrovascular pathology on the symptomatology and course of Alzheimer's disease (AD). The link between stroke and AD is probably higher than expected by chance for the following reasons: (i) both pathologies share genetic risk factors such as the epsilon 4 allele of the apolipoprotein E gene; (ii) AD patients have changes in the brain vessels that may lead to either ischemic or hemorrhagic stroke or white matter changes or both; (iii) there is evidence of an increased risk of stroke in AD patients; (iv) there is evidence of a frequent association of AD and stroke at autopsy. Because of the summation of the various types of lesions, stroke lesions may lead to an increase progression of cognitive decline in AD patients. Recognition of a vascular component in a dementia syndrome is therefore useful for the management of AD patients. Whether an optimal management of risk factors for stroke may delay the clinical expression of dementia in patients with preclinical Alzheimer pathology should be evaluated.
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Affiliation(s)
- F Pasquier
- Department of Neurology, University of Lille, France
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34
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Rosenstein LD. Differential diagnosis of the major progressive dementias and depression in middle and late adulthood: a summary of the literature of the early 1990s. Neuropsychol Rev 1998; 8:109-67. [PMID: 9834489 DOI: 10.1023/a:1025628925796] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There is a preponderance of research on the neuropsychology of the various dementias. There are also direct comparisons between two or more dementias available in the literature. This paper sought to summarize the most recent literature, primarily from 1990 through mid-1996, including recent reviews of the literature from previous decades. The purpose was to provide, in one location, a summary of neuropsychological (i.e., cognitive, motor, and psychiatric) characteristics of major noninfectious, progressive dementias and depression of middle and late adulthood. It is hoped that this review, particularly a summary table provided, will serve as a guide in the differential diagnosis of the dementias by clinicians. In addition to Alzheimer's disease, vascular dementias, Parkinson's disease, Lewy body dementia, Huntington's disease, and frontal lobe dementia, the impact of depression on cognitive functioning is covered given the frequency with which neuropsychologists are asked to differentiate depression from primary dementia.
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Affiliation(s)
- L D Rosenstein
- Department of Psychiatry, Scott & White Clinic and Memorial Hospital, Temple, Texas 76508, USA
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Jenkins M, Malloy P, Salloway S, Cohen R, Rogg J, Tung G, Kohn R, Westlake R, Johnson EG, Richardson E. Memory processes in depressed geriatric patients with and without subcortical hyperintensities on MRI. J Neuroimaging 1998; 8:20-6. [PMID: 9442586 DOI: 10.1111/jon19988120] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In this study, 12 patients over age 60 with depression with moderate to severe subcortical hyperintensities (SH) localized to the periventricular white matter were identified by quantitative MRI. Using the California Verbal Learning Test, they were compared with 12 age-, education-, and severity-matched patients with depression with minimal white matter changes on specific aspects of memory performance. Patients with cortical lesions, neurologic or systemic illness affecting cognition, and history of substance abuse were excluded. Patients in the group with high SH showed reduced use of semantic encoding strategies (p < 0.05), reduced learning efficiency (p < 0.05), and a greater discrepancy between free recall and recognition discriminability (p < 0.05) than their low SH counterparts. This pattern of performance on memory tasks is similar to that found in previous studies to be associated with subcortical degenerative disorders such as Huntington's and Parkinson's diseases. Geriatric patients with depression with SH may represent a subgroup with greater subcortical involvement, with associated cognitive and functional decline.
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Affiliation(s)
- M Jenkins
- Brown University School of Medicine, Providence, RI 02906, USA
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36
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Abstract
A possible relation between cerebral white-matter injury and dementia was intuitively attributed by Alzheimer to changes affecting the small penetrating vessels that supply the cerebral white matter. Several observations support the view that white-matter changes detectable by neuroimaging may contribute to cognitive deficits in the elderly. But many questions concerning this matter remain partially answered. In this communication we review: (1) Selected anatomic features of the blood vessels supplying the white matter; (2) possible pathogenetic mechanisms responsible for the white-matter changes; (3) observations on humans and animals suggesting a causal relationship between ischemia/hypoxemia and white-matter injury; (4) epidemiologic studies linking white-matter abnormalities with cognitive disorders. We conclude that abnormalities in the small vessels caused by aging and arterial hypertension, or other processes (cerebral amyloid angiopathy, CADASIL) together with systemic circulatory disturbances, such as abrupt variations in blood pressure values or cardiac diseases, may be the substrate of selective white-matter injury. The damage is structurally characterized by incomplete infarction or selective cellular injury.
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Affiliation(s)
- L Pantoni
- Department of Neurological and Psychiatric Sciences, University of Florence, Italy
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Mendez MF, Cherrier MM, Perryman KM. Differences between Alzheimer's disease and vascular dementia on information processing measures. Brain Cogn 1997; 34:301-10. [PMID: 9220093 DOI: 10.1006/brcg.1997.0923] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study evaluated information processing differences between 30 vascular dementia (VaD) patients, 30 Alzheimer's disease (AD) patients, and 30 normal elderly (NE) controls. They were administered a complex reaction time test, a continuous performance test (CPT), and a neuropsychological battery. Compared to NE, both dementia groups had significantly slower motor reaction times and made more errors on the CPT. Compared to AD patients, the VaD patients were slower in stimulus categorization time and had increasing omission errors and persistent commission errors throughout the CPT trial, VaD, which usually includes frontal-subcortical circuit injury, can impair mental speed and stimulus response initiation.
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Affiliation(s)
- M F Mendez
- Department of Neurology, University of California at Los Angeles, USA
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Shyu WC, Lin JC, Shen CC, Hsu YD, Lee CC, Shiah IS, Tsao WL. Vascular dementia of Binswanger's type: clinical, neuroradiological and 99mTc-HMPAO SPET study. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1996; 23:1338-44. [PMID: 8781138 DOI: 10.1007/bf01367589] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In 24 patients with vascular dementia of Binswanger's type (VDBT) and 14 age-matched neurologically normal volunteers, we investigated the relationship between clinical features, white matter lesions (leuco-araiosis) and cerebral atrophy on computed tomographic (CT) scan, and regional cerebral blood flow. All subjects underwent the Mini-Mental State Examination of Taiwan, version 1 (MMSE-T1), for assessing the severity of cognitive impairment. The patients were subdivided into two groups, one with mild to moderate (group I, MMSE-T1 scores: 11-24, n=11), and the other with severe dementia (group II, MMSE-T1 scores: below 10, n=13). White matter degeneration was evaluated with densitometric methods. Loss of brain parenchyma was estimated with seven linear measurements (Evan's ratio, third ventricle ratio, width of temporal horn tip, anterior-posterior length of temporal horn, anterior-posterior length of Sylvian fissure and width of frontal interhemispheric fissure) by CT scans. Regional cerebral blood flow was determined with technetium-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission tomography (SPET). In neuroimaging studies, subcortical leuco-araiosis was localized at the frontal region in group I patients and scattered diffusely in group II patients. 99mTc-HMPAO SPET analysis revealed reduction of regional cerebral blood flow in the frontal lobe in group I patients and widespread reduction of regional cerebral blood flow in group II patients. A correlation between frontal leuco-araiosis and perfusion defect of the frontal pole was demonstrated in group I patients, showing findings typical of subcortical dementia. There was no difference in frontal atrophic measurements between group I patients and controls. Ratios of volumes of lost brain parenchyma and leuco-araiosis were significantly higher in group II patients than in the age-matched controls, corresponding to a diffuse cerebral perfusion defect. These results suggest that patients with VDBT have early frontal lobe involvement with posterior progression. Patients with mild VDBT are more likely to show reduction of frontal cerebral blood flow and leuco-araiosis, while those with severe VDBT are more likely to have diffuse leuco-araiosis, cerebral hypoperfusion and brain atrophy.
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Affiliation(s)
- W C Shyu
- Department of Neurology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, R.O.C
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Kuwabara Y, Ichiya Y, Sasaki M, Yoshida T, Fukumura T, Masuda K, Ibayashi S, Fujishima M. Cerebral blood flow and vascular response to hypercapnia in hypertensive patients with leukoaraiosis. Ann Nucl Med 1996; 10:293-8. [PMID: 8883704 DOI: 10.1007/bf03164735] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Both arteriosclerosis and leukoaraiosis have a close relationship with hypertension, but the relationship between cerebral hemodynamics and leukoaraiosis in hypertensive patients has not been fully examined. To clarify this issue, we measured the regional cerebral blood flow (rCBF) and cerebrovascular response to hypercapnia in hypertensive patients with various degrees of leukoaraiosis. The subjects consisted of 7 normotensive normal controls and 17 hypertensive patients. The hypertensive patients were divided into three groups according to the severity of white matter lesions (leukoaraiosis) on MRI and the presence of dementia, namely, (1) negative or mild leukoaraiosis without dementia, (2) moderate to severe leukoaraiosis without dementia and (3) severe leukoaraiosis with dementia. Both the rCBF and the cerebrovascular response to hypercapnia were measured by the O-15 H2O bolus-injection method and positron emission tomography. The rCBF in hypertensive patients without dementia did not decrease when compared with the normotensive controls, but the rCBF in hypertensive patients with dementia markedly decreased in the cerebral cortices and white matter. On the other hand, the cerebrovascular response to hypercapnia declined with the severity of leukoaraiosis, and it decreased most severely in patients with severe leukoaraiosis and dementia. Our results indicate that the reduction in the cerebral hemodynamic reserve capacity has a close relationship with the severity of leukoaraiosis in hypertensive patients, although the rCBF is maintained in hypertensive patients without dementia, and suggest that arteriosclerotic change reduces cerebrovascular CO2 response and causes a leukoaraiosis in hypertensive patients.
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Affiliation(s)
- Y Kuwabara
- Department of Radiology, Faculty of Medicine, Kyushu University
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van Swieten JC, Staal S, Kappelle LJ, Derix MM, van Gijn J. Are white matter lesions directly associated with cognitive impairment in patients with lacunar infarcts? J Neurol 1996; 243:196-200. [PMID: 8750560 DOI: 10.1007/bf02444014] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Forty-four patients (mean age 66, SD 8 years) with either clinical evidence of a focal lacunar syndrome (n = 36) or with disorders of memory or gait (n = 8) in the presence of a lacunar infarct on CT were studied for cognitive functioning and for the presence of white matter lesions on MRI. MR images were assessed by a neurologist and a neuroradiologist blinded to the clinical data. Thirty-six patients had one or more lacunar infarcts on CT or MRI (in the thalamus in 5, in the caudate nucleus in 3 and in the internal capsule or corona radiata in the remaining patients). Twelve patients had multiple infarcts. Severe lesions of the white matter were found in 13 patients, mild to moderate lesions in 20 patients. Scores on Digit Span, Digit Symbol and delayed recall of the 15-Words test were significantly lower in group with severe lesions, whilst there was a trend in the same direction for the Cognitive part of the Cambridge Examination of Mental Disorders in the Elderly, the Trailmaking B, Stroop colour interference test and the delayed visual reproduction of the Wechsler Memory Scale. These findings suggest that diffuse lesions of the white matter are an independent factor in the pathogenesis of intellectual dysfunction, also in patients with lacunar infarcts, but a truly independent analysis is difficult because the most severe involvement of the white matter tended to be associated with the largest number of lacunar infarcts.
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Affiliation(s)
- J C van Swieten
- Department of Neurology, University of Utrecht, The Netherlands
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Kalra L. A proposal for an integrated multidisciplinary assessment battery in elderly stroke patients. AGING (MILAN, ITALY) 1995; 7:197-201. [PMID: 8547377 DOI: 10.1007/bf03324315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- L Kalra
- Orpington Stroke Unit, Bromley Hospitals NHS Trust, Bromley, Kent, UK
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Becker T, Retz W, Hofmann E, Becker G, Teichmann E, Gsell W. Some methodological issues in neuroradiological research in psychiatry. J Neural Transm (Vienna) 1995; 99:7-54. [PMID: 8579809 DOI: 10.1007/bf01271468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An outline is given of some of the methodological issues discussed in neuroradiological research on psychiatric illness. Strengths and shortcomings of magnetic resonance imaging (MRI) in depicting and quantifying brain structures are described. Temporal lobe anatomy and pathology are easily accessible to MRI, whereas limits on anatomical delineation hamper approaches to frontal lobe study. White matter hyperintense lesions are sensitively depicted by MRI, but specificity is limited. Distinction of vascular and primary degenerative dementia is considerably improved by CT and MRI analysis. Computed tomography (CT) and MRI have enhanced the understanding of treatable organic psychiatric disorders, e.g., normal pressure hydrocephalus. Subcortical and white matter pathology has been replicated in CT and MRI studies of late-onset psychiatric disorders, clinical overlap with cerebrovascular disease or neurodegeneration may be of import. Transcranial sonography findings of brainstem structural change specific to unipolar depression may contribute to the understanding of affective psychoses. Magnetic resonance spectroscopy and functional MRI are likely to stimulate psychiatric research in the future.
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Affiliation(s)
- T Becker
- Department of Psychiatry, University of Würzburg, Federal Republic of Germany
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Ikeda T, Fukushima T, Sonoda K, Kani S, Ando M, Okabe H, Araki S, Kinjo Y. Auditory and colored visual P300 in patients with sequelae of subacute myelo-optico-neuropathy. ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1994; 91:265-74. [PMID: 7523076 DOI: 10.1016/0013-4694(94)90190-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To study the cognitive function in 13 patients with sequelae of subacute myelo-optico-neuropathy (SMON), event-related potentials (ERPs) were elicited with tones, clicks, and colored visual stimuli in different tasks. P300 latency was delayed, and P300 amplitude reduced or absent in 5 patients (38%), although neuropsychological assessment for dementia did not differ between patients and 21 age-matched normal controls. P300 and N200 latencies with the tone/tone auditory stimuli and N200 latency with the visual stimuli were significantly delayed, but the latencies of early components (N100 and P200) were not delayed. These findings suggest that SMON patients may have cognitive dysfunction to a slight degree.
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Affiliation(s)
- T Ikeda
- Department of Laboratory Medicine, Kumamoto University School of Medicine, Japan
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Tsuda Y, Yamada K, Hayakawa T, Ayada Y, Kawasaki S, Matsuo H. Cortical blood flow and cognition after extracranial-intracranial bypass in a patient with severe carotid occlusive lesions. A three-year follow-up study. Acta Neurochir (Wien) 1994; 129:198-204. [PMID: 7847164 DOI: 10.1007/bf01406505] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The long-term effect of extra-intracranial arterial bypass on cerebral circulation was examined. Cortical blood flow and cognitive ability were evaluated pre- and up to 3 years post-bypass in a 58-years-old man with severe carotid occlusive lesions, who presented with 3 transient cerebral ischaemic attacks which resulted in mental deterioration over 3 years. Regional cerebral blood flow (rCBF) was evaluated pre- and up to 33 months post-bypass by 123Iodine N-isopropyl-p-iodoamphetamine (IMP) single-photon emission CT (SPECT). Mental abilities were evaluated before and up to 33 months after surgery by the Hasegawa's dementia rating scale (HDRS). Pre-operatively, cerebral angiography showed left carotid siphon occlusion and hypoplastic stenosis of left anterior cerebral artery with collaterals from the anterior communicating artery. CT and MRI showed left temporo-parietal borderzone infarction and an enhanced T 1 lesion by gadolinium-DTPA at left periventriculum. rCBF showed extensive hypoperfusion in left anterior-parieto-temporal-cortex. HDRS scores deteriorated apparently on days 3, 5, which recovered gradually on days 8, 10, 75 after onset of mental deterioration. A bypass was performed 4 months after onset. rCBF showed gradual recovery in the left anterior-parietal cortex up to 33 months after bypass. Semiquantitative rCBF showed gradual decreases of regional asymmetry after the bypass. HDRS scores returned to their maximum up to 37 months after onset. Three-year follow-up shows improved cortical rCBF and cognition after the bypass.
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Affiliation(s)
- Y Tsuda
- Second Department of Internal Medicine, Kagawa Medical School, Japan
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Abstract
Frontal lobe executive control functions (ECF) are proposed as a source of problem behavior in dementia. The behavior and personality changes that follow frontal lobe brain damage overlap with those seen in dementia, and frontal lobe structural and metabolic lesions can be demonstrated across a variety of dementing illnesses. ECF help explain the importance of social and environmental cues in the production of disruptive behavior and suggest interpersonal strategies for their control. This model has considerable face validity and leads to several testable hypotheses.
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Affiliation(s)
- D R Royall
- Department of Psychiatry, Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas
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Tsuda Y, Yamada K, Hayakawa T, Hirakawa F, Ayada Y, Ohkawa M, Tanabe M, Matsuo H. Recovery of cortical blood flow and dementia after superficial temporal-middle cerebral artery bypass in a patient with severe carotid occlusive lesions: A two-year follow-up study. J Stroke Cerebrovasc Dis 1992; 2:240-3. [DOI: 10.1016/s1052-3057(10)80058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Waxman SG, Ransom BR, Stys PK. Non-synaptic mechanisms of Ca(2+)-mediated injury in CNS white matter. Trends Neurosci 1991; 14:461-8. [PMID: 1722366 DOI: 10.1016/0166-2236(91)90046-w] [Citation(s) in RCA: 97] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Clinical deficits after injury to the CNS are due, in large part, to dysfunction of white matter (myelinated fiber tracts), including descending and ascending tracts in the spinal cord. A crucial set of questions, in the search for strategies that will preserve or restore function after CNS injury, centers on the pathophysiology of, and mechanisms underlying recovery of conduction in, CNS white matter. These questions are relevant both to spinal cord injury, and to brain infarction, which frequently affects white matter.
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Affiliation(s)
- S G Waxman
- Dept of Neurology, Yale University School of Medicine, New Haven, CT 06510
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