High frequency of silent brain infarcts associated with cognitive deficits in an economically disadvantaged population

OBJECTIVE: Using magnetic resonance imaging, we aimed to assess the presence of silent brain vascular lesions in a sample of apparently healthy elderly individuals who were recruited from an economically disadvantaged urban region (São Paulo, Brazil). We also wished to investigate whether the findings were associated with worse cognitive performance. METHODS: A sample of 250 elderly subjects (66-75 years) without dementia or neuropsychiatric disorders were recruited from predefined census sectors of an economically disadvantaged area of Sao Paulo and received structural magnetic resonance imaging scans and cognitive testing. A high proportion of individuals had very low levels of education (4 years or less, n=185; 21 with no formal education). RESULTS: The prevalence of at least one silent vascular-related cortical or subcortical lesion was 22.8% (95% confidence interval, 17.7-28.5), and the basal ganglia was the most frequently affected site (63.14% of cases). The subgroup with brain infarcts presented significantly lower levels of education than the subgroup with no brain lesions as well as significantly worse current performance in cognitive test domains, including memory and attention (p<0.002). CONCLUSIONS: Silent brain infarcts were present at a substantially high frequency in our elderly sample from an economically disadvantaged urban region and were significantly more prevalent in subjects with lower levels of education. Covert cerebrovascular disease significantly contributes to cognitive deficits, and in the absence of magnetic resonance imaging data, this cognitive impairment may be considered simply related to ageing. Emphatic attention should be paid to potentially deleterious effects of vascular brain lesions in poorly educated elderly individuals from economically disadvantaged environments.

Retracción palpebral de causa neurológica: presentación de tres pacientes, interpretación patogénica / Eyelid retraction of neurologic origin: report of three cases

Eyelid retraction, has received limited attention and it has passively been interpreted as the result of an overactive levator palpebrae superioris muscle secondary to midbrain injury. However, eyelid retractions can occur in other neurological diseases, not directly related with the midbrain. We report three patients who developed eyelid retraction. One patient had a bilateral eyelid retraction, related with Creutzfeldt-Jakob disease (CJD). Another patient had a unilateral right eyelid retraction associated with a thalamic-mesencephalic infarct. The third patient had a bilateral pontine infarction on magnetic resonance imaging. In the patient with CJD, eyelid retraction did not subside. Among patients with infarctions, the retraction persisted after focal symptoms had subsided, showing an evolution that was apparently independent of the basic process. The analysis of these patients allows us to conclude that the pathogenesis of eyelid retraction includes supranuclear mechanisms in both the development and maintenance of the phenomenon. Unilateral or bilateral eyelid retraction does not alter the normal function of eyelid, which ever had normal close eye blink. In these reported cases, a hyperactivity of levator palpebrae superioris muscle was clinically ruled out.

Lacunar Infarction in Type 2 Diabetes Is Associated with an Elevated Intracranial Arterial Pulsatility Index

PURPOSE: The arterial pulsatility index (PI) is measured by transcranial Doppler ultrasonography (TCD) and is postulated to reflect the vascular resistance distal to the artery being examined. An increased PI of the intracranial artery is often reported with diabetes mellitus (DM), old age, hypertension, intracranial hypertension, vascular dementia, and small artery disease. Microvascular complication of DM, which may contribute to cerebral infarction, involves the small perforating artery and may influence the PI of the proximal artery. MATERIALS AND METHODS: We performed a TCD examination in patients with type 2 DM with acute lacunar infarction (DML, n=35), type 2 DM without cerebral infarction (DMO, n=69), and in control cases with no DM or cerebral infarction (control group, n=41). We then compared the TCD findings among these groups. RESULTS: The PI was significantly higher in the DML and DMO groups than in the control group (1.05, 0.93, 0.73. respectively, for the right middle cerebral artery; 1.04, 0.90, 0.73, respectively, for the left middle cerebral artery; 0.97, 0.89, 0.70, respectively, for the basilar artery). The PI was also significantly higher in the DML group than in the DMO group for both middle cerebral arteries. The flow velocity was comparable among the three groups. CONCLUSION: The elevated PI of the intracranial arteries may reflect diabetic cerebral microvascular complications. The PI measurement using TCD may be a useful predictor of lacunar infarction in type 2 DM patients.

role of MRI in the diagnosis of vertebrobasilar dolicoectasia

Aging changes especially when it is associated with hypertension and arteriosclerosis may lead to elongation, dilatation and so tortuosity of the involved arteries. The clinical effect of this is either pressure symptoms or ischemic events. This phenomenon is called Dolicoectasia. It is defined as fusiform dilatation and elongation of an artery. The process can involve vertebral, basilar, posterior or anterior inferior cerebellar or labyrinthine arteries, The Vertebrobasilar system is more commonly involved by this process. The clinical presentations are non specific and could be related to wide range of pathological vascular and non vascular causes. The aim of the study was to demonstrate different MRI and MRA patterns of The vertebrobasilar Dolicoectasia as a respectable cause for neurological symptoms and signs including nerve palsies and posterior fossa infarctions. One hundred patient with neurological symptoms related to the portrait of the vertebrobasilar system were evaluated with MRI and MRA. Patients were referred from the outpatient clinics with retrolabyrinthine Hearing deficit, pulsatile tinnitus. facial spasm, trigeminal neuralgia or vertebrobasilar stroke features. The average age was 59 years with a standard deviation of 12 years. The females represent one third of cases while the males were two thirds. The most common presentation was vertebrobasilar insufficiency [VBI] in thirty percent, followed by facial spasm and pulsatile tinnitus in twenty three percent, trigeminal neuralgia in twenty one percent, cerebellar infarctions in seventeen percent and brain stem stroke in nine percent. Basilar and vertebral arteries were more commonly involved, while Labyrinthine artery was the least involved vessel The commonly missed vertebrobasilar Dolicoectasia should be considered as a respectable cause for neurological symptoms and signs including nerve palsies and posterior fossa infarctions. MRI and MRA are the modalities of choice to demonstrate the wide range of vascular changes occurred with Dolicoectasia and also their effect as nerve compression or vascular occlusions by embolization or thrombosis. The most common nerves to be involved is the trigeminal, acoustic and facial ones. If the radiologist does not consider this pathological entity as a cause for cranial nerve compression palsy, false negative results could occur. Vertebrobasilar Dolicoectasia [VBD] is considered uncommon, but this consideration should be changed in searching for causes of posterior fossa neurological symptoms especially in nerve compression or strokes