Decreased awareness of cognitive deficits in patients with mild dementia of the Alzheimer type.

OBJECTIVE: To study the unawareness of cognitive deficits in patients with mild dementia of Alzheimer type (DAT). DESIGN: Retrospective study. We surveyed the medical records of outpatients meeting the NINCDS-ADRDA criteria for probable DAT who were able to complete the Cognitive Difficulties Scale (CDS) and had a close informant relative (IR) who could complete the family form of the same questionnaire. SETTING: A department of neurology in a general teaching hospital. SUBJECTS: Eighty-eight patients, aged 73.2+/-8.6 years with a mean MMSE score of 22.5+/-3.2. Fifty-two of the 88 patients had a follow-up examination after a mean interval of 21 months. METHODS: Awareness of cognitive deficits was mainly assessed as the difference between the scores on the CDS completed by the IR and the patient (Index of Unawareness, IU). Two secondary assessments of unawareness were performed: (1) an assessment by the clinician on the basis of the patient's answers to questions probing the awareness of memory deficits; (2) an evaluation by the IR of the frequency of behavioural manifestations of unawareness in everyday life. SPECT was performed in 78 patients to study the relationship between unawareness and the topography of perfusion deficits. RESULTS: Awareness of the cognitive deficits varied greatly between patients, according to the assessment method used and the stage of progression of the disease. Most patients with mild DAT were cognitively aware of their cognitive deficits but failed to appraise their severity and their consequences in everyday life. Decreased awareness was positively correlated with age and perfusion deficits in the frontal regions and negatively with the anxious symptomatology. However, the main correlate of unawareness was apathy. CONCLUSION: The nature of unawareness of cognitive deficits appeared to be more dimensional than categorical. In patients with mild dementia, decreased awareness appeared to be more related to affective disturbances, especially to emotional deficit or apathy, than to cognitive deficits.

Indium-111 antimyosin scintigraphy before and after coronary bypass surgery: unexpected preoperative myocardial uptakes.

The present study was designed to evaluate 111In-antimyosin scintigraphy in detecting pre- and post-operative myocardial infarction in patients undergoing coronary artery bypass surgery. Fab antimyosin scintigraphy has been shown to be sensitive and specific in detecting myocardial necrosis and to be potentially valuable in situations where other criteria are not reliable. In a previous study, postoperative antimyosin uptakes occurred in 82% of the studied patients. Sixteen consecutive patients with an indication of coronary artery surgery were assessed by preoperative coronary angiography, serial electrocardiograms, and myocardial scanning with 111Indium-labeled antimyosin antibodies performed before and after operation. In four patients, a recent myocardial infarction (1 to 3 months) was detected with an accurate localization when compared to the classic criteria of myocardial infarction. One more patient with a 21-year old myocardial infarction showed an intense uptake whereas there was no recent acute coronary event. Four other patients had an unexpected preoperative uptake, since there were no acute coronary events in their medical history. All preoperative scintigraphic uptakes were still present on the second scan performed postoperatively in these nine patients. Only one patient showed a new postoperative uptake when compared to the preoperative scan which was normal; this postoperative septal infarct was confirmed by a postoperative coronary angiography. Extracardiac uptakes (sternum and ribs) were frequently observed after operation and might hamper the interpretation of postoperative scintigrams. Unexpected preoperative uptakes may be related to non diagnosed small necrosis. A preoperative reference scan is required for an accurate interpretation of a postoperative 111In-antimyosin uptake. Moreover, extracardiac uptakes may limit the interpretation of perioperative cardiac damage.

[Indium III monoclonal antimyosin antibody scintigraphy for the detection of chronic myocardial infarction apart from the acute phase]. / Scintigraphie aux anticorps monoclonaux antimyosine marqués à l'indium 111 pour la détection de l'infarctus du myocarde en dehors de la phase aiguë.

Fab antimyosin scintigraphy has been shown to be sensitive and specific in detecting acute myocardial necrosis. This study was designed to evaluate the preoperative frequency of Indium-111 (In-111) antimyosin myocardial uptake in patients scheduled for coronary artery bypass surgery. The scintigraphic results were compared with other criteria of myocardial infarction (MI). Sixteen consecutive patients were included. Recent MI (1 to 3 months) were detected in four patients, with an accurate localization in three cases when compared to the classic criteria for MI. Two more patients had old Q wave MI: one did not show any uptake in the territory of MI whereas the second patient with a 21 year old infarct without recent acute coronary events showed an intense uptake consistent with the ECG and angiographic localization. Four other patients with stable angina showed limited uptakes that were unexpected, since there were no acute coronary events in their medical history, and ECG. Their left ventricle angiography were considered as normal. In these four cases, the scintigraphic location corresponded to a territory supplied by an occluded coronary artery (n = 2) or by a coronary artery with a tight stenosis requiring a bypass graft (n = 2). These antimyosin uptakes are probably related to small necroses which did not modify the ECG and did not alter the ventricular segmental wall motion. We conclude: 1) recent MI are detected by In-111 antimyosin scintigraphy; 2) In-111 antimyosin uptake may occur in patients without a diagnosis of recent myocardial infarction and correspond to older MI or limited necroses without detectable changes of the ECG and left ventricle angiography.

[Value of antimyosin monoclonal antibody scintigraphy in the diagnosis of acute myocardial infarction]. / Intérêt de la scintigraphie aux anticorps monoclonaux antimyosine dans le diagnostic d'infarctus du myocarde rudimentaire.

A 53 year old woman developed chest pain with transient anterior subepicardial ischaemic ECG changes and a mild increase in serum myocardial enzyme concentrations. She was admitted to hospital some time later but there were no electrocardiographic signs of infarction. Echocardiography was considered to be normal. Coronary angiography showed no significant stenosis and there were no segmental wall motion abnormalities on left ventriculography. The diagnosis of a non-Q wave infarct was confirmed by myocardial scintigraphy using antimyosin monoclonal antibodies labelled with Indium 111. The site and size of the necrosis were also determined by this non-invasive investigation.

[Quantified EEG in the diagnosis of Alzheimer's type dementia]. / Apport de l'EEG quantifié au diagnostic de démence de type Alzheimer.

79 subjects (mean age 70.2 ans, 31 males, 48 females) selected as probable dementia of the Alzheimer type, at the early stage of the disease and 17 normal aged people (mean age: 72.2, 5 males, 12 females) were recorded with a 16 channel computerized-EEG (C-EEG) with topographical analysis of the observed changes and with classical visual analysis of the EEG. Quite simple C-EEG parameters as mean dominant frequency (MF) and alpha to theta ratio are able to discriminate patients from normal with a greater accuracy than visual analysis. The values of 8.6 for the MF and 1.3 for the alpha/theta ratio are proposed as cut off values between normal and DAT patients. The topographical analysis appear to be of no additional usefulness in the discrimination of the two groups.

[Comparison of SPECT and quantified EEG features in Alzheimer's type dementia]. / Comparaison des aspects SPECT et EEG quantifié dans les démences de type Alzheimer.

Forty-one patients with probable dementia of the Alzheimer type (DAT) have been studied by computerized EEg (C-EEG) and single photon emission tomography (SPECT) using 123-IMP. Four groups have been distinguished according to SPECT hypoperfusion topography: frontal, temporo-parietal, fronto-parietal and fronto-temporo-parietal. C-EEG parameters were much more disturbed in the 2 latter than in the 2 former groups. Thus a normal C-EEG could indicate a dominant frontal or temporo-parietal form of DAT. Therefore some bias due to duration or rate of disease progression cannot be excluded. So far the important finding is that EEG changes are diffuse and do not reflect the topography of SPECT hypoperfusion questioning the value of EEG topographical analysis in DTA.

[EEG value for the prediction of the evolution of Alzheimer's type dementia]. / Intérêt de l'EEG pour la prédiction de l'évolution des démences de type Alzheimer.

Twenty patients selected as probable dementia of the Alzheimer type (DAT) have been examined two times during a mean follow-up period of 14.5 months. Two groups have been distinguished at the end of this period: a cognitively impaired one and a stable one. EEG features at T1, at T2 or the difference T1-T2 does not allow an accurate and predictive discrimination between the two groups. But we cannot conclude that EEG is useless for prediction of the rate of progression of the disease in DAT because most of the cognitively stable patients are also stable for mean frequency. So mean frequency could be an interesting marker of evolutivity but this to be tested with more patients including more subjects reaching the severe stage of dementia.

[Diagnostic value of pulsed Doppler in atheromatous renal insufficiency. A study of 32 patients]. / Intérêt diagnostique du Doppler pulsé dans l'insuffisance rénale athéromateuse. Etude de 32 patients.

RATIONALE: atheromatous stenosis of both renal arteries, or of the artery of a functionally solitary kidney is a frequent cause of renal failure in the elderly. Atheromatous Ischemic Renal Insufficiency (AIRI) can be ameliorated by surgery or angioplasty. However, such procedures can be hazardous in a patient with extensive aortic atheromatous plaques. This justified a study of the validity of Pulsed Doppler (PD), a diagnostic procedure less invasive than renal angiography in AIRI. OBJECTIVES: to evaluate the diagnostic interest of PD in AIRI, using renal angiography as a criterion of adequacy. METHODS: renal arteries PD (Ultramak-4, 3.5 and 5 Mhz probes) followed by renal angiography (Seldinger). "Significant" stenosis = 50% on angiography. "Positive" PD = turbulences and/or acceleration. PATIENTS: 32 patients were investigated for suspected AIRI on the grounds of 1) age greater than 50; 2) atheromatous background and 3) renal insufficiency with no other evident etiology, or rapidly declining GFR in such a patient treated with ACE inhibitors. RESULTS: 16/32 angiographies disclosed significant stenosis of at least 1 renal artery. 56 renal arteries were investigated with both angio. and PD. Prevalence of stenoses was 16/56. PD had 93.7% sensitivity and 55% specificity. Positive predictive value was 45.5% and negative predictive value was 95.7%. Specificity was 80% when PD disclosed acceleration. CONCLUSIONS: negative PD is sufficient argument to reconsider the indication of renal angiography in a high risk pt with suspected AIRI.

Clipping of the anterior communicating artery to eliminate the contralateral blood supply in supratentorial large AVM of the carotid system. A report of 22 cases.

Large supratentorial arteriovenous malformations (AVMs) of the carotid system are vascularized by the ipsilateral internal carotid artery (ICA) and often, in addition, by the contralateral ICA via the anterior communicating artery (ACoA). In these AVMs we have previously advocated (1981) multiple staged operations with the progressive reduction of the blood stream passing through the AVM. In twenty-two cases, starting in 1983, the reduction of the blood stream into the shunt has been performed as a first operation by placing a clip on the middle of the ACoA through a pterional approach on the opposite side of the AVM before radical open surgery. Results were excellent when considering the control angiogram and the measurement of the blood velocity in the ICA opposite to the AVM side. There were no neurological complications and no mortality.

Classification of supratentorial arteriovenous malformations. A score system for evaluation of operability and surgical strategy based on an analysis of 66 cases.

A classification of arteriovenous malformations (AVM) is proposed, which is based on a retrospective analysis of the records and results of radical operation in 57 patients between 1983 and 1990. It represents the new developments and more recent technical facilities which influence operability of supratentorial AVMs. Predictability of outcome has been settled upon three groups of factors: anatomical, haemodynamical, and clinical. Anatomical factors are localisation and sectorisation of AVM, determination, caliber and straightening of feeding arteries. Haemodynamical factors are volume of AVM and vascular autoregulation, circulatory velocity of red blood cells in the main arteries of the neck and brain tissue cellular steal. Clinical factors are age, previous rupture of AVM, associated diseases and malformations of vital organs. Each of these factor groups has been divided into parameters to which a code number from 0 to 5 according to the severity of the considered parameter has been attributed. When a contraindication for radical surgery was clearly obvious, as, for example, an AVM with extension to the upper brain stem, number 10 was given. This grading has been done by a team of four persons (3 neurosurgeons including the senior author, and one biophysicist). By adding up all code numbers an Operability Score for a given patient is defined by the number of points, with a minimum of 3 and a maximum of 69. In cases with a score higher than 30 surgery is not advisable. A score between 21 and 30 indicates that always several staged operations are required, whilst only some of the patients with a score between 11 and 20 may require two stage operative treatment. The AVM in patients with a score under 10 can always be radically excised in a single stage operation. We have been able to demonstrate that the Operability Score allows a reliable prediction of outcome, thus giving indications and contraindications for surgery, and also for the surgical strategy. Moreover, we have explained why surgery had been refused in 9 additional cases during the same period. The causes of 8 fatalities out of 57 surgical cases are analyzed. These 57 cases represent a systematically explored series of the senior author; his experience is based upon 295 personal AVM cases (1958-1990).

A new haemodynamic factor in cerebral AVM. Aspiration from the venous system demonstrated in two cases of pedonculo-Galen AVM successfully cured by occlusion of the superior longitudinal sinus.

Using a Doppler Mark 500 of ATL we measured the systolic and diastolic velocity of the red cells into the main arteries of the neck (diastolic rate cm/sec) thus approaching the flow in two cases of upper brain stem AVM with a unique drainage into the superior longitudinal sinus through an enlarged vein of Galen and a falcine sinus. Because of the desperate clinical condition of the children it was decided to stop the high blood flow by closing the aspiration coming from the low pressure of the venous system above and below the site of union between the malformation and the superior longitudinal sinus. An intra-operative and post-operative measurement of the diastolic rate showed a radical effect of the closure of the superior longitudinal sinus. The demonstration of this aspirative factor has allowed us to classify an AVM as a haemodynamic push-pull malformation.

[Successful separation in 1974 of craniopagus twins united at the vertex. Indications, technics, follow-up after 14 years]. / Séparation réussie en 1974 de jumelles craniopages unies par le vertrex. Indications, techniques, évolution sur 14 ans.

On July 22, 1974, 55 days after delivery, the separation of female craniopagus twins united at the vertex was performed. This case was very similar to the case published by Voris in 1957 after separation in 1955. Surgery was decided because the neurological examination was normal in both twins, because there was no body malformation, because the angiogram as well as isotopic scintigraphy showed two normal brains, two superior sagittal sinuses and two torcular areas with a short venous union in the middle of the bone defect. In addition, Sophie and Sonia were suffering from respiratory disturbances due to their position. Surgery was easy (90 min) using the operative microscope; intubation and placing intravascular tubes for hemodynamic monitoring were difficult and lasted 4 hours. After all it took 14 years and 23 operations to complete the reconstructive surgery of the bone and skin. Cranioplasty was finally performed using vitallium plates. On their 14th birthday a neuropsychological investigation was performed with an IQ of 94 in Sophie and 76 in Sonia. Both girls are nubile and enjoy a normal school attendance.

[Carotido-vertebral study with ultrasonics]. / Exploration carotido-vertébrale par les ultrasons.

Sonotomography, associated with the Doppler test, permits an atraumatic exploration of quite a satisfactory precision of the carotid and vertebral arteries in their cervical portion. This type of exploration was used in patients with parietal lesions of these vessels, arterio-venous malformations or a cerebral arterial spasm. In these lesions of the wall and lumen of the arteries, the problem is to reconsider the place of this examination as compared to arteriography with injection of contrast material, from the diagnostic as well as pre-therapeutic standpoint.

[Noninvasive diagnosis of deep venous thromboses by Doppler ultrasound]. / Diagnostic non invasif des thromboses veineuses profondes par écho-Doppler.

A Duplex ultrasound technique combining real time ultrasound B imaging with pulsed Doppler investigation was used for non-invasive exploration of peripheral venous trunks. A series of 72 patients (21 men and 51 women including 26 pregnant women) was investigated by the examination of deep venous trunks of upper limbs (68 cases) and of lower limbs (4 cases). Lesions were identified in 19 cases (26%), including 9 total thrombosis, 6 partial thrombosis, 3 sequelae of a previous thrombosis and 1 case of valve incontinence. Morphologic (caliber, wall, intraluminal echos) and functional (expansion, flow rate, compression) features establishing diagnosis are discussed. Phlebography findings in 8 of the 15 cases of thrombosis (total or partial) provided very satisfactor correlation, clinical correlation being considered sufficient in the other cases. This duplex technique is a reliable, reproducible and non-invasive method for diagnosis and for follow up of medical treatment of thrombophlebitis.