Akiko Ishiwata

Benzodiazepine receptor imaging with iomazenil SPECT in aphasic patients with cerebral infarction

To investigate the relationship between prognosis of aphasia and neuronal damage in the cerebral cortex, we evaluated the distribution of central-type benzodiazepine receptor (BZR) binding in post-stroke aphasics with [123I]iomazenil and SPECT. We performed iomazenil SPECT in six aphasie patients (aged from 45 to 75 years; all right-handed) with unilateral left cerebral infarction. Three patients showed signs of Broca’s aphasia and the other three Wernicke’s aphasia. Cerebral blood flow (CBF) imaging was performed with [123I]iodoamphetamine (IMP). The regions of interest (ROIs) on both images were set in the cerebral cortex, cerebellar cortex and language-relevant area in both hemispheres. Three patients were classified in the mild prognosis group and the other three in the moderate prognosis group. The left language-relevant area was more closely concerned with the difference in aphasie symptoms than the right one in both BZR and CBF distribution, but the ipsilateral to the contralateral ratio (I/C ratio) in the language-relevant areas in the BZR distribution was significantly lower in the moderate prognosis group than in the mild prognosis group, although no difference was seen for these values between the two groups in the CBF distribution. These results suggest that BZR imaging, which makes possible an increase in neuronal cell viability in the cerebral cortex, is useful not only for clarifying the aphasie symptoms but also for evaluating the prognosis of aphasia in patients with cerebral infarction.

The potentially protective effect of donepezil in Alzheimer's disease.

Background/Aims: Donepezil is an acetylcholinesterase inhibitor used to treat Alzheimers disease (AD). In this study, we used a voxel-based specific regional analysis system for AD (VSRAD) to analyze the hippocampal volume and to assess the pharmacologic effects of donepezil as a disease modifier. Methods: A total of 185 AD patients underwent MRI, 120 (43 men and 77 women, 77.8 ± 7.1 years) without and 65 (29 men and 36 women, 78.4 ± 6.0 years) with donepezil treatment. VSRAD was compared in both groups and against a database of 80 normal subjects. The Z-score was used to assess the degree of hippocampal atrophy. Results: No significant difference between the groups was found for age, sex, or Z-scores, but a significant difference was found for mean Mini-Mental State Examination (MMSE) scores (p = 0.02, Students t test). Single regression analysis showed no significant association between Z-scores and MMSE scores in the treated group (p = 0.494), but a significant association in the untreated group (p = 0.001) was observed. This implies that the MMSE score becomes lower when the Z-score is higher in the untreated group, whereas there is no significant trend in the treated group. Conclusion: Donepezil affects the relationship between hippocampal volume and cognitive function and may therefore have a pharmacologic effect as a disease modifier.

Urinary albumin-to-creatinine ratio is associated with white matter lesions severity in first-ever stroke patients

BACKGROUND The presence of white matter lesions (WML) is an indicator of small vessel disease; however, the underlying pathological mechanisms are still unclear. We aimed to investigate the association of estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) with WML severity in first-ever stroke patients. METHODS We retrospectively enrolled 284 consecutive patients (177 male; median age 72years) admitted to our stroke center between May 2010 and January 2012. eGFR and UACR measurements were performed on admission. WML severity was assessed using the Fazekas classification. Severe WML was defined as a Fazekas grade of 2 or higher. The impact of eGFR and UACR on severe WML was evaluated using multiple logistic regression analysis. RESULTS Age (P<0.0001), sex (P=0.0094), eGFR (P=0.0173), UACR (P=0.0001), hypertension (P=0.0436), and brain natriuretic peptide (P=0.0354) were significantly associated with severe WML. On multivariable logistic regression analysis, high UACR (≥39.6mg/g creatinine, P=0.039), but not low eGFR (≤74ml/min/1.73m2, P=0.3672), was independently associated with severe WML. Comparisons between the UACR levels showed that severe WML was more frequent in the UACR ≥300mg/g creatinine group than in the UACR <30.0mg/g creatinine group after multivariate adjustment (OR, 2.25; 95% CI, 1.04-5.00; P=0.039). However, there was no significant association between eGFR and severe WML. CONCLUSIONS Our data suggest that high UACR, but not eGFR, is independently associated with severe WML.

Homonymous Hemianopsia Associated with Probable Alzheimer's Disease

Posterior cortical atrophy (PCA) is a rare neurodegenerative disorder that has cerebral atrophy in the parietal, occipital, or occipitotemporal cortices and is characterized by visuospatial and visuoperceptual impairments. The most cases are pathologically compatible with Alzheimers disease (AD). We describe a case of PCA in which a combination of imaging methods, in conjunction with symptoms and neurological and neuropsychological examinations, led to its being diagnosed and to AD being identified as its probable cause. Treatment with donepezil for 6 months mildly improved alexia symptoms, but other symptoms remained unchanged. A 59-year-old Japanese woman with progressive alexia, visual deficit, and mild memory loss was referred to our neurologic clinic for the evaluation of right homonymous hemianopsia. Our neurological examination showed alexia, constructional apraxia, mild disorientation, short-term memory loss, and right homonymous hemianopsia. These findings resulted in a score of 23 (of 30) points on the Mini-Mental State Examination. Occipital atrophy was identified, with magnetic resonance imaging (MRI) showing left-side dominance. The MRI data were quantified with voxel-based morphometry, and PCA was diagnosed on the basis of these findings. Single photon emission computed tomography with (123)I-N-isopropyl-p-iodoamphetamine showed hypoperfusion in the corresponding voxel-based morphometry occipital lobes. Additionally, the finding of hypoperfusion in the posterior associate cortex, posterior cingulate gyrus, and precuneus was consistent with AD. Therefore, the PCA was considered to be a result of AD. We considered Lewy body dementia as a differential diagnosis because of the presence of hypoperfusion in the occipital lobes. However, the patient did not meet the criteria for Lewy body dementia during the course of the disease. We therefore consider including PCA in the differential diagnoses to be important for patients with visual deficit, cognitive impairment, and cerebral atrophy in the parietal, occipital, or occipitotemporal cortices. A combination of imaging methods, including MRI and single photon emission computed tomography, may help identify probable causes of PCA.

INCIDENCE AND PREDICTIVE FACTORS OF COGNITIVE DYSFUNCTION SIX MONTHS AFTER ACUTE STROKE

Background: There is general acknowledgement of the importance of early diagnosis of dementia, yet there are still high rates of undetected dementia internationally. The aim of this crosssectional study was to determine the sociodemographic characteristics associated with possible undetected dementia in a large sample of community-dwelling older New Zealanders. Methods: The sample consisted of older people (age 65) who had received the homecare version of the international Residential Assessment (interRAI HC 9.1) over a 2-year period and who were screened positive for possible dementia on the interRAI’s Cognitive Performance Scale. People with possible alternative explanations for cognitive impairment such as depression and other neurological conditions were excluded. The 5202 eligible individuals were categorized into two groups: (1) those with a recorded diagnosis of dementia (64%) and (2) those without a recorded diagnosis of dementia (36%). Logistic regression was used to evaluate the association between individual characteristics and possible undetected dementia. Results: The mean age for the possible undetected dementia group (UDG) was significantly higher than the diagnosed dementia group (DDG) (83.6 years, SD67.7 vs 82.6 years, SD67.0; p1⁄40.000). Compared with the DDG, subjects in the possible UDG were less likely to be married or in a de facto relationship (37.6% vs 54.5%, p1⁄40.000) and more likely to be living alone (42.8% vs 26.4%, p1⁄40.000) (OR1⁄42.01, CI1⁄41.75-2.30). Compared with the DDG, subjects in the possible UDG were significantly (i) less likely to have participated in social activities of long standing interest (42.6% vs 52.6%, p1⁄40.000) (OR1⁄41.37, CI1⁄41.211.56), (ii) more likely to have experienced major life stressors (52.1% vs 35.2% p1⁄40.000) (OR1⁄41.88, CI1⁄41.65-2.14), and (iii) more likely to report limited access to home or rooms in home (8.6% vs 5.9%, p1⁄40.000) (OR1⁄41.44, CI1⁄41.13-1.84). Ethnicity had a significance effect on the diagnosis of dementia (p1⁄40.012); Asian people has a greater risk of being in the possible undetected dementia group (OR1⁄41.91, CI1⁄41.33-2.74). Conclusions: Our results could help to identify the individual characteristics that play a role in the under-diagnosis of dementia in the local context, and guide interventions to promote early diagnosis in vulnerable groups. P2-300 INCIDENCE AND PREDICTIVE FACTORS OF COGNITIVE DYSFUNCTION SIX MONTHS AFTER ACUTE STROKE

Lewy Body Dementia as an Underlying Etiology for Posterior Cortical Atrophy Initially Presented with Visual Agnosia and Alexia: A Case Report

Posterior cortical atrophy (PCA) is a neurodegenerative disorder with cerebral atrophy in the parietal, occipital, or occipitotemporal cortices, and is characterized by visuospatial and visuoperceptual impairments. The majority of the disorder is compatible pathologically with Alzheimer’s disease (AD). However, many patients show no memory loss until late stages of the disease. We encountered a case where a combination of several imaging modalities, in conjunction with symptoms and neuropsychological exams, led not only to a diagnosis of PCA but also identified its underlying etiology. A 62-year-old Japanese man presented to ophthalmology with visual impairment and without abnormalities in his visual acuity or visual fields. Alexia was identified, particularly pertinent to reading Kanji, at the neurology clinic. His initial Mini-Mental State Examination (MMSE) revealed a score of 27/30 points with delayed recall (-2) and constructional apraxia (-1). The score dropped to 25 points six months later. Brain MRI demonstrated occipital atrophy. Brain single photon emission computed tomography (SPECT) showed hypoperfusion in the medial and lateral occipital lobes. The myocardial meta-iodobenzylguanidine (MIBG) scintigraphy showed no evidence of myocardial postganglionic sympathetic dysfunction. Posterior cortical atrophy (PCA) was diagnosed in conjunction with the symptoms, including alexia and visual impairment. He developed symmetric parkinsonism one year later. Lewy body dementia (DLB) was thus considered as the underlying etiology for the PCA. Additionally, alexia pertinent to reading Kanji has not been reported before. We herein report this rare case.