Bungo Okuda

Apathy and Depression in Parkinson Disease

The purpose of this study was to investigate the prevalence and clinical correlates of apathy and depression in Parkinson disease (PD), and to clarify whether apathy can be dissociated from depression. One hundred fifty patients with PD completed the Beck Depression Inventory Second Edition (BDI-II), Starkstein’s Apathy Scale (AS), and a quality of life (QOL) battery. Hoehn and Yahr (HY) staging, the Unified Parkinson’s Disease Rating Scale (UPDRS), and the Mini-Mental State Examination (MMSE) were performed on the same day. Apathy (AS score ≥ 16) was diagnosed in 60% of patients and depression (BDI-II score ≥ 14) in 56%. Apathy coexisted with depression in 43% of patients, compared with depression without apathy in 13% and apathy without depression in 17%. Apathy scale score was significantly correlated with UPDRS scores, HY stage, and age, whereas BDI-II score was correlated only with UPDRS scores. Both AS and BDI-II scores were negatively correlated with QOL. However, multiple regression analysis revealed that depression was strongly and negatively associated with emotional well-being and communication, whereas apathy was mainly associated with cognition and stigma. These findings suggest that apathy and depression may be separable in PD, although both are common in patients with PD and are associated with QOL.

Parkinsonism after acute cadmium poisoning

A 64-year-old man suffered from acute exposure to cadmium, followed by multiple organ failure. Three months after exposure, the patient developed parkinsonian features. The case suggests that cadmium intoxication may damage the basal ganglia, resulting in parkinsonism.

Slowly progressive limb-kinetic apraxia with a decrease in unilateral cerebral blood flow.

We report two patients with slowly progressive motor disorders, whose principal manifestations were asymmetric limb‐kinetic apraxia and muscle rigidity. In both patients MRI revealed no responsible lesion, whereas single photon emission computed tomography (SPECT) showed a decrease in cerebral blood flow (CBF) in the unilateral hemisphere. One patient with mainly right‐sided apraxia had a decreased CBF in the left central region between the frontal and parietal cortices, and the other patient with left‐sided apraxia in the right parietal cortex. In agreement with asymmetric clinical symptoms, the regional CBF decrease in the unilateral cortical areas including the frontal and parietal cortices may suggest a degenerative disease, presumably diagnosed as having corticobasal degeneration.

Corticosteroid-responsive parkinsonism associated with primary Sjögren's syndrome

A 74-year-old woman with primary Sjögrens syndrome confirmed by salivary gland biopsy presented with parkinsonism. Magnetic resonance imaging (MRI) of the brain revealed multiple small high intensity lesions in the deep white matter, basal ganglia and pons on T2-weighted images. Treatment with L-dopa failed to improve the parkinsonian features. After the initiation of prednisolone 30 mg/day, the parkinsonian signs and symptoms significantly improved. Some lesions on MRI were decreased in size after corticosteroid therapy. These findings suggest that parkinsonism associated with primary Sjögrens syndrome is at least in part attributable to small vessel vasculopathy such as focal inflammation or edema.

The role of the left somatosensory cortex in human hand movement

Hemispheric dominance for motor control in the human brain is still unclear. Here we propose asymmetric sensorimotor integration during human hand movements. We investigated the dexterity of hand movements and related sensory functions in four right-handed patients with cerebrovascular lesions in the postcentral gyrus. To clarify the distributions of cortical damage, semiquantitative analysis of regional cerebral blood flow (rCBF) was performed using single photon emission computed tomography (SPECT), and a three-dimensional surface display was generated from SPECT. Scores on motor and sensory tasks and rCBF values in the patients were compared with those in control subjects. All patients presented with asymmetric clumsiness of complex finger movements, in association with impairments of combined sensations such as stereognosis. These findings were indicative of a disorder of sensory information processing necessary to guide the movements. Two patients with left hemispheric damage showed bilateral clumsy hands, predominating on the right side, while the other two patients with right hemispheric damage showed only a left clumsy hand. In agreement with asymmetric clumsiness, measurement of rCBF along with a three-dimensional surface display revealed cortical hypoperfused areas, mainly in the perirolandic cortices, comprising the primary motor and somatosensory cortices. Perirolandic cortical hypoperfusion was bilateral in the two patients with bilateral clumsy hands, but only on the right side in the other two patients with left clumsy hands. These results suggest a dominant role of the left somatosensory cortex in sensorimotor integration for complex finger movements of humans.

Comparison of Brain Perfusion in Corticobasal Degeneration and Alzheimer’s Disease

To compare brain perfusion between corticobasal degeneration (CBD) and Alzheimer’s disease (AD), we measured regional cerebral blood flow (rCBF) semiquantitatively with single-photon emission computed tomography in 10 patients with CBD and 16 with AD. There was no significant difference in age or illness duration between the patients with CBD and AD. Mini-Mental State Examination scores were significantly lower in the AD patients than in the CBD patients. All CBD patients showed asymmetric akinetic-rigid syndrome and limb apraxia. Four CBD patients were demented, and 1 AD patient had parkinsonism. Compared with 12 age-matched control subjects, the average of the left and right rCBF values for the CBD patients was significantly reduced in the prefrontal, anterior cingulate (AC), medial premotor, sensorimotor (SM), posterior parietal (PP) and superior temporal (ST) cortices as well as in the basal ganglia (BG) and thalamus (Th), while the prefrontal, PP and ST cortices were significantly hypoperfused in the AD patients. In the CBD patients, rCBF was significantly less in the AC and SM cortices, and in the Th and BG, and significantly greater in the PP cortex than in the AD patients. Interhemispheric differences of rCBF in the inferior prefrontal and SM cortices were significantly greater in the CBD patients than the AD patients. It is concluded that rCBF comparison may aid in differentiating CBD from AD.

Focal cortical hypoperfusion in corticobasal degeneration demonstrated by three-dimensional surface display with123I-IMP: a possible cause of apraxia

To clarify cortical lesions responsible for apraxia in corticobasal degeneration (CBD), we reconstructed three-dimensional surface images from single-photon emission computed tomography (SPECT) data withN-isopropyl-p[I-123]-iodoamphetamine in two patients with CBD. Both had limb-kinetic apraxia (LKA) and one also had constructional apraxia (CA). Both showed asymmetrical cortical hypoperfusion in the perirolandic area. The patient with CA had unilateral hypoperfusion in the posterior parietal area. Thus, cortical hypoperfusion in the perirolandic area corresponded to LKA, and that in the posterior parietal area to CA.

Electrophysiological comparison between corticobasal degeneration and progressive supranuclear palsy

Multimodal evoked potentials were recorded in four patients with corticobasal degeneration (CBD), four patients with progressive supranuclear palsy (PSP) and 15 normal control subjects. CBD and PSP patients showed significant prolongation of the N200 and P300 latencies of auditory event-related potentials compared with controls. Patients with CBD showed significant prolongation of interpeak latencies between N13 and N20 of short-latency somatosensory evoked potentials compared with the controls and patients with PSP. The present results show that the two diseases have different electrophysiologic features.

Primitive reflexes distinguish vascular parkinsonism from Parkinson's disease.

OBJECTIVES Although vascular parkinsonism (VP) occurs frequently in the elderly, its clinical features have not been investigated in detail, particularly in comparison with Parkinsons disease (PD). The goal of this study is to clarify the diagnostic value of pathological reflexes in differentiating between VP and PD. PATIENTS AND METHODS In 132 patients with PD and 55 with VP, pathological reflexes, including snout reflex (SR), palmomental reflex (PMR), corneomandibular reflex (CMR), jaw reflex (JR), Hoffmann reflex (HR), and extensor plantar response (EPR), were evaluated. RESULTS The percentage of each pathological reflex elicited in two groups (VP:PD) was as follows: SR (78:30), PMR (53:26), CMR (9:6), JR (33:12), HR (29:11), and EPR (25:8). The prevalence of pathological reflexes, except for CMR, was significantly higher in the VP patients than in the PD patients. In particular, SR and PMR were more frequent than upper motor neuron signs in the VP patients. The sensitivity and specificity of either SR or PMR for VP were 84% and 82%. CONCLUSION Snout and palmomental reflexes are useful tools in the differentiation between VP and PD.

Asymmetric changes in somatosensory evoked potentials correlate with limb apraxia in corticobasal degeneration

To clarify the underlying mechanism of limb apraxia in corticobasal degeneration (CBD), we investigated somatosensory evoked potentials in 5 patients with CBD, as compared with 12 age‐matched control subjects. All patients presented with asymmetric limb apraxia, particularly of limb‐kinetic type. N20 latencies were significantly prolonged following median nerve stimulation on the more apraxic side, but not on the less apraxic side. These results suggest that limb apraxia in CBD may, at least in part, be due to a disorder of somatosensory information processing involving the parietal cortex.