Norman Gordon

Factors associated with early presentation of acute stroke.

Background and Purpose Patients with stroke symptoms commonly delay many hours before seeking medical attention. We sought to explore the factors associated with early presentation of stroke patients to physicians. Methods We prospectively studied 100 consecutive acute stroke patients presenting to three large, urban medical centers. Using a standardized, structured interview and chart review, we assessed patient education about stroke, risk factors, clinical features of the stroke, source of stroke recognition, and timing of presentation. We did not study the distance from the site of stroke onset to the site of physician contact. Results Stroke onset time was known in 96 of the patients. Mean patient age was 71.3 years, 79% had at least one stroke risk factor, 26% had prior transient ischemic attack, 19% had prior stroke, 74% had some high school education, and 86% had regular physicians. Only 8% had been previously educated about stroke symptoms. Eighty one percent of strokes were ischemic. The mean time to physician contact was 13.4 ± 2.3 hours (median, 4.0 hours) and to neurologist contact was 21.2 ± 2.9 hours. A skewed distribution of presentation times accounts for the mean-median differences. A small number of patients presenting very late could have an effect on the correlations between presentation time and the variables studied. Early presentation time was associated with increased age, the sudden onset of a stable deficit, and recognition that the symptoms signified stroke. Only the sudden onset of a stable deficit correlated independently with early presentation time (P=.0048). There was no correlation between presentation time and prior transient ischemic attack or stroke, headache, vomiting, loss of consciousness or seizures at onset, or stroke subtype, but a type II error could not be excluded. Conclusions Despite their education level, regular health care, and risk factors, especially prior stroke and transient ischemic attack, these patients were not knowledgeable about stroke and delayed many hours before contacting physicians. The course of symptoms and recognition that they signified stroke were associated with earlier presentation. Patient education focused on groups at risk may hasten the presentation and treatment of acute stroke.

Gender Differences in the Behavioral Manifestations of Alzheimer's Disease

OBJECTIVE: To examine the relationship between gender and specific types of behavior problems that occur in patients with Alzheimers disease.

Tuberculous brain abscess in a patient with hiv infection: case report and review

S ince 1986, the human immunodeficiency virus (HIV) epidemic in the United States has been associated with a resurgence of tuberculosis, causing substantial mortality in patients with the acquired immunodeficiency syndrome (AIDS). ‘z2 In particular, the increased incidence of extrapulmonary manifestations has complicated the diagnosis and early treatment of tuberculosis.3 Much of the resurgence has occurred among HIV-infected drug users in large cities, the diagnosis of tuberculosis often constituting their initial AIDS-defining condition.4a5 HIV infection in intravenous drug users increases the risk of active tuberculosis.‘j This most commonly results from the reactivation of latent tuberculosis infection, but the risk of disease from recent person-to-person transmission is also increased.7-‘0 Tuberculosis, in turn, accelerates the course of HIV disease progression.” Both HIV-infected individuals and injection-drug users are also at increased risk of disease caused by multidrug-resistant strains of Mycobacterium tuberculosis.‘2 Drug resistance increases the likelihood of treatment failure and relapse, and further spread of tuberculosis, thereby complicating both the treatment of infected individuals and the public health measures needed to control tuberculosis.‘3m17 The clinical presentation of tuberculosis in patients with HIV infection varies considerably depending on the degree of immunosuppression, with atypical features occurring more frequently at low CD4 T lymphocyte counts.” Where immune function is preserved, classical chest radiograph findings of reactivation tuberculosis such as cavitation and upper-lobe infiltrates may occur. With HIV-induced immunosuppression, tuberculosis often involves diffuse pulmonary infiltrates, pleural effusions, or hilar lymphadenopathy. Most strikingly, in patients with advanced HIV disease, there is a high frequency of extrapulmonary tuberculosis: extrathoracic lymphadenopathy, miliary disease, and central nervous

The relationship of subcortical MRI hyperintensities and brain volume to cognitive function in vascular dementia.

The relationship between MRI findings (i.e., subcortical hyperintensities; SH, whole brain volume) and the cognitive dysfunction of vascular dementia (VaD) was examined. Participants included 24 persons that met NINDS-AIREN criteria for VaD (MMSE = 19.9 +/- 4.2) and underwent comprehensive neuropsychological assessment and MRI brain imaging. The volume of subcortical hyperintensities (SH) was strongly associated with executive-psychomotor performance, but not with performance across other cognitive domains or global cognitive functional level. Conversely, WBV was strongly associated with global cognitive functioning and performance across most cognitive domains (memory, language, visual integration), but not with executive-psychomotor functioning. The failure of SH to account for either the global dementia evident in these VaD patients or impairments across most cognitive domains suggests that deep subcortical white matter disease may only indirectly contribute to the global cognitive dysfunction of VaD. That WBV emerged as a stronger correlate of dementia raises further questions regarding the cerebral mechanisms that contribute to the development of VaD.

Relative contributions of the cerebellar vermis and prefrontal lobe volumes on cognitive function across the adult lifespan

Recent research has revealed significant relationships between the vermian regions of the cerebellum and cognitive functions typically associated with prefrontal lobe function. These relationships are believed to be supported by anatomical connections between the distant brain regions. Recent evidence also suggests that age-related reductions in the posterior vermis are associated with age-related decline in frontal lobe cognitive functions, but these studies did not consider concomitant age-related atrophy of the prefrontal lobes. In the present study we addressed this issue by examining cognitive and structural MRI data obtained from 251 adults ranging in age from 18 to 79. Cognition was examined with a computerized cognitive battery and volumes of the cerebellar vermian regions and the prefrontal lobes were determined using quantitative morphometry. Results of the study revealed that both prefrontal and vermian volumes were smaller in older adults compared to younger adults, and both volumes correlated with cognitive performances in the older individuals. However, after controlling for prefrontal volume, the relationships between cognitive function and vermian volumes were eliminated, whereas prefrontal lobe volume remained significantly related to cognitive function after controlling for vermian volumes. These results suggest that while a reduction in cerebellar vermian volume does not significantly relate to normal age-related cognitive decline, prefrontal volume is significantly related to cognitive aging. Our results are consistent with the frontal aging hypothesis.

Dementia Rating Scale Performance: A Comparison of Vascular and Alzheimer's Dementia

Differences in the pattern of neuropsychological dysfunction associated with Alzheimers disease (AD) and vascular dementia (VaD) were examined using the Dementia Rating Scale (DRS). We examined three groups of patients: (1) Patients with AD; (2) patients with single stroke (CVA); and (3) patients with multiple cerebral infarctions (MI). Comparisons of cognitive dysfunction were conducted on patients that met the DRS criteria for dementia. Dementia groups were similar in age, education, and severity of dementia. Comparisons of the AD and two VaD groups across the specific DRS-scales (Attention, Conceptualization, Construction, Initiation/Perseveration, and Memory) indicated that patients with AD were more impaired on the DRS-Memory while the patients with VaD were more impaired on the DRS-Construction. Additionally, patients with VaD related to MI scored lower on the DRS-Initiation/Perseveration as compared to patients with AD, and patients with AD scored lower on the DRS-Conceptualization as compared to patients with VaD related to CVA. These results are indicative of qualitative differences in the pattern of cognitive deficits associated with the two types of dementia.

Long-Term Citicoline (Cytidine Diphosphate Choline) Use in Patients with Vascular Dementia: Neuroimaging and Neuropsychological Outcomes

Background: Cytidine diphosphate choline (citicoline) has been previously shown to have efficacy in reducing the functional impairments associated with acute stroke. Citicoline is thought to have neuroprotective benefits and has been used for the treatment of chronic cerebrovascular disorders, though its effectiveness has not been fully tested. This randomized, double-blind clinical trial was conducted to determine whether daily citicoline treatment improves neurocognitive and neuroimaging outcome over 12 months among patients diagnosed with vascular dementia (VaD). Methods: 30 patients diagnosed with VaD, based upon NINDS-AIREN and DSM-IV criteria, were randomized and treated with either 500 mg of citicoline or placebo twice per day. Patients were assessed at baseline, and at 6, and 12 months on a battery of neurocognitive tests. Neuroimaging measures of total brain volume and subcortical/periventricular hyperintensity (SH) volume on magnetic resonance imaging (MRI) were collected at baseline and the 12-month follow-up. Results: The citicoline and placebo treatment groups did not differ in their neuropsychological performance at baseline and the 12-month follow-up. Significant declines in neuropsychological performance were noted, as well as significantly increased SH and reduced total brain volumes on MRI for both groups at the 12-month follow-up. Conclusions: The efficacy of long-term citicoline treatment for cognitive impairment and neuropathological decline in those patients already meeting criteria for VaD does not appear to be substantiated by the current study.

Performance on the Mattis Dementia Rating Scale in patients with vascular dementia: relationships to neuroimaging findings.

Impairment on screening measures such as the Mattis Dementia Rating Scale (MDRS) provides evidence of demen tia in patients with cerebrovascular disease. However, the relationships between neuroimaging findings and performance on the MDRS in vascular dementia (VD) have not been determined. In the present study, we exam ined the relationships between subcortical hyperintensity (SH) volume and whole brain volume (WBV) on the subscales and total score of the MDRS. Results revealed that SH accounted for a significant amount of variance on the Initiation/Perseveration and Construction subscales, whereas WBV accounted for a significant amount of vari ance on the Memory subscale. The total score on the MDRS was found to be significantly related to WBV but not SH. These results suggest that subcortical damage and brain volume account for different aspects of cognitive decline in VD and that overall cognitive impairment may reflect cortical and subcortical involvement. (J Geriatr Psychiatry Neurol 2001; 14:33-36).

Single Photon Emission Computed Tomography, Magnetic Resonance Imaging Hyperintensity, and Cognitive Impairments in Patients With Vascular Dementia

Background. The relationship between subcortical hyperintensity (SH) on magnetic resonance imaging (MRI), cortical perfusion on single photon emission computed tomography (SPECT), and cognitive function is not well understood. The authors examined these relationships in individuals with vascular dementia (VaD), paying particular attention to frontal lobe function to determine whether the presence of SH on MRI was associated with frontal hypoperfusion on SPECT, which in turn would be associated with impairments of executive‐attention function. Methods. Patients with vascular dementia (n= 26) were assessed on neurocognitive tests and brain MRI and SPECT. SH volume was quantified from the axial T2‐weighted fluid attenuated inversion recovery MRI. Total counts of activation across voxels for 12 cortical regions of interest were determined from SPECT. Perfusion ratios of both total cortical and frontal activation relative to cerebellum activation were derived, and regression analyses were performed to determine the relationships between cognitive, MRI, and SPECT indices. Results. SH volume on MRI was significantly associated with frontal lobe perfusion, but not with global cortical perfusion as measured by SPECT. Frontal lobe perfusion did not consistently correlate with performance on measures of executive function, although both total and frontal perfusion ratios were significantly associated with other cognitive functions. Conclusions. These results suggest that a functional “disconnection” between the frontal lobes and subcortical structures does not fully account for the magnitude of global cognitive impairment in VaD. Cortical perfusion as measured by SPECT appears to be associated with cognitive performance, but not specifically executive‐attention dysfunction. Additional studies are needed to further examine the relationship between subcortical and cortical function in VaD.

The Global Deterioration Scale: Relationships to Neuropsychological Performance and Activities of Daily Living in Patients with Vascular Dementia

In the present study, we examined the relationships between ratings on the Global Deterioration Scale (GDS) and activities of daily living and cognitive function in 39 individuals with vascular dementia (VaD). The results of the study revealed significant correlations between GDS rating and performance on cognitive tests, including memory and overall cognitive ability. In addition, the GDS was significantly related to ratings of instrumental activities of daily living. Comparisons between patients with VaD with GDS scores between 4 and 6 (n = 21) and patients with scores between 2 and 3 (n = 18) revealed greater cognitive and functional deficits in the group with higher GDS scores. Further, the GDS score accurately classified 87% of the patients with VaD. These findings provide support for the validity of the GDS in general staging of dementia severity of VaD. (J Geriatr Psychiatry Neurol 2002; 15:50-54).