Early-onset Alzheimer disease: the contribution of neuroimaging for the diagnosis.

The diagnosis of Alzheimer disease (AD) at an early age of onset may be a challenging task. The diagnosis of such a type of dementia may be even more difficult when concomitant depressive symptoms occur. We report the case of a 51-year-old woman who was admitted at a Psychiatric Day Hospital presenting with depressive symptoms, visuospatial deficits, apraxia, and minor memory loss. The patient underwent long-term antidepressant therapy, but despite the improvement of depressive symptoms, there was progressive cognitive deterioration. Otherwise, the prior clinical history was unremarkable, and there was no family history of dementia. The clinical examination revealed cognitive deficits in several domains. The patient scored 12 in the Mini-Mental State Examination. Routine laboratory tests were normal. Magnetic resonance (MR) imaging showed global brain volume loss more pronounced than would be expected for someone of the patient's age, especially in the precuneus-a pattern of posterior cortical atrophy consistent with the diagnosis of early-onset AD. Images obtained with 99mTc-HMPAO single-photon emission computed tomography (SPECT) also revealed marked brain hypoperfusion involving the left parietal lobe, far beyond the regions of brain volume loss. This clinical case report illustrates the relative contribution of both MR imaging and SPECT for the diagnosis of dementia in a patient with concomitant depressive symptoms. Apart from contributing to the diagnosis of dementia beyond the traditional exclusionary approach, neuroimaging is increasingly being used to classify its particular subtypes. The role of neuroimaging role in AD is also supported by a recent proposal of revised diagnostic criteria, which take into account abnormal biomarkers of disease.

[Neurocognitive dysfunction after valve surgery]. / Disfunção neurocognitiva após cirurgia valvular.

Neurocognitive dysfunction is, nowadays, reported as one of the most frequent complications of cardiac surgery, with documented potential to have a negative impact on quality of life. Notwithstanding, the cognitive evaluation is almost exclusively restricted to research contexts, being depreciated in clinical settings. Cognitive functioning changes have mostly been investigated in patients submitted to coronary artery bypass grafting, with data reporting to valvular surgery still being extremely rare. In spite of the dramatic reduction of rheumatic valvular pathology in developed countries, the burden of degenerative diseases owed to prolonged life expectancy keep the valvular heart diseases as a major Public Health problem. Beyond the intraoperative damage, which [corrected] is believed to occur in both surgeries, in valvular surgery the deficits might turn out to be the result of cumulative lesions caused by microemboli originating from prosthetic cardiac valves. Etiology of cerebral injury related to cardiac surgery is not completely elucidated, probably representing a complex interaction between cerebral microemboli, global cerebral hypoperfusion, inflammation and genetic susceptibility. The exact identification of the involved mechanisms is still a great challenge. The available data concerning cognitive performance after valvular surgery point out that this intervention appears to be more harmful towards cognition than the coronary artery bypass grafting, even when considering biological valve replacement. Thus, the type of valve prosthesis appears not to be the prevailing factor in cognitive complains maintenance, with age and type of valvular intervention being the most influent factors on long-term prognosis. A notable variability between results of different studies may arise from diverse investigational methodologies and from factors related with difficulties inherent to the cognitive assessment, such as the diverse methods used for evaluation and the presence of a remarkable number of confounding factors. Investigation on valvular surgery neurocognitive effects is still in a very incipient period, being crucial to accurately establish the exact influence of the specific variables of this particular patient's group, such as the type of surgery and valve prosthesis. Furthermore, the clarification of the pathophysiological mechanisms subjacent to neurocognitive dysfunction might represent an important step to look for potential preventive or therapeutic strategies that could ameliorate brain function after cardiac surgery.

[Impact of psychosocial factors on heart valve surgery]. / Impacto dos factores psicossociais na cirurgia valvular cardíaca.

Despite the raising number of cardiac valve surgeries performed each year, it is evident the lack of studies concerning the psychosocial aspects and their impact on prognostic in these patients. This connection is well established on cardiovascular disease and on patients submitted to cardiac surgery of ischemic states, like coronary artery bypass surgery; in these cases recent studies revealed that the presence of depressive and/or anxious symptoms worsened the prognostic with significant impact on the quality of life. The aim of the present literature review it is to take knowledge of the psychosocial factors on patients submitted to valve surgery and the possible pathophysiological hypotheses that may clarify that connection. The identification of non surgical predictive factors, of psychosocial nature, might allow an early approach with a prognostic improvement.