Insight, grey matter and cognitive function in first-onset psychosis

BACKGROUND: Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures. AIMS: Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis.METHOD: Voxel-based magnetic resonance imaging data were acquired from 82 individuals with psychosis and 91 controls assessed with a brief neuropsychological test battery. Insight was measured using the Schedule for the Assessment of Insight. RESULTS: The principal analysis showed reduced general neuropsychological function was linked to poor symptom relabelling ability. A subsequent between-psychosis group analysis found those with no symptom relabelling ability had significant global and regional grey matter deficits primarily located at the posterior cingulate gyrus and right precuneus/cuneus. CONCLUSIONS: The cingulate gyrus (as part of a midline cortical system) along with right hemisphere regions may be involved in illness and symptom self-appraisal in first-onset psychosis.

Differing patterns of brain structural abnormalities between black and white patients with their first episode of psychosis

BACKGROUND: African-Caribbean and black African people living in the UK are reported to have a higher incidence of diagnosed psychosis compared with white British people. It has been argued that this may be a consequence of misdiagnosis. If this is true they might be less likely to show the patterns of structural brain abnormalities reported in white British patients. The aim of this study therefore was to investigate whether there are differences in the prevalence of structural brain abnormalities in white and black first-episode psychosis patients. METHOD: We obtained dual-echo (proton density/T2-weighted) images from a sample of 75 first-episode psychosis patients and 68 healthy controls. We used high resolution magnetic resonance imaging and voxel-based methods of image analysis. Two separate analyses were conducted: (1) 34 white British patients were compared with 33 white British controls; (2) 41 African-Caribbean and black African patients were compared with 35 African-Caribbean and black African controls. RESULTS: White British patients and African-Caribbean/black African patients had ventricular enlargement and increased lenticular nucleus volume compared with their respective ethnic controls. The African-Caribbean/black African patients also showed reduced global grey matter and increased lingual gyrus grey-matter volume. The white British patients had no regional or global grey-matter loss compared with their normal ethnic counterparts but showed increased grey matter in the left superior temporal lobe and right parahippocampal gyrus. CONCLUSIONS: We found no evidence in support of our hypothesis. Indeed, the finding of reduced global grey-matter volume in the African-Caribbean/black African patients but not in the white British patients was contrary to our prediction.

Different effects of typical and atypical antipsychotics on grey matter in first episode psychosis: the AESOP study

Typical antipsychotic drugs act on the dopaminergic system, blocking the dopamine type 2 (D2) receptors. Atypical antipsychotics have lower affinity and occupancy for the dopaminergic receptors, and a high degree of occupancy of the serotoninergic receptors 5-HT2A. Whether these different pharmacological actions produce different effects on brain structure remains unclear. We explored the effects of different types of antipsychotic treatment on brain structure in an epidemiologically based, nonrandomized sample of patients at the first psychotic episode. Subjects were recruited as part of a large epidemiological study (’SOP: aetiology and ethnicity in schizophrenia and other psychoses). We evaluated 22 drug-free patients, 32 on treatment with typical antipsychotics and 30 with atypical antipsychotics. We used high-resolution MRI and voxel-based methods of image analysis. The MRI analysis suggested that both typical and atypical antipsychotics are associated with brain changes. However, typicals seem to affect more extensively the basal ganglia (enlargement of the putamen) and cortical areas (reductions of lobulus paracentralis, anterior cingulate gyrus, superior and medial frontal gyri, superior and middle temporal gyri, insula, and precuneus), while atypical antipsychotics seem particularly associated with enlargement of the thalami. These changes are likely to reflect the effect of antipsychotics on the brain, as there were no differences in duration of illness, total symptoms scores, and length of treatment among the groups. In conclusion, we would like to suggest that even after short-term treatment, typical and atypical antipsychotics may affect brain structure differently.

The structural brain correlates of neurological soft signs in AESOP first-episode psychoses study

Patients with schizophrenia and related psychoses have an excess of minor neurological abnormalities (neurological soft signs of unclear neuropathological origin. These include poor motor coordination, sensory perceptual difficulties and difficulties in sequencing complex motor tasks. Neurological soft signs seem not to reflect primary tract or nuclear pathology. It still has to be established whether neurological soft signs result from specific or diffuse brain structural abnormalities. Studying their anatomical correlates can provide not only a better understanding of the aetiopathogenesis of soft signs, but also of the pathophysiology of schizophrenia. Suprisingly few studies have investigated the brain correlates of neurological soft signs. In the present study, we investigated the relationship between brain structure and neurological soft signs in an epidemiologically based sample of 77 first-episode psychosis patients. We used the Neurological Evaluation Scale for neurological assessment and high-resolution MRI and voxel based methods of image analysis to investigate brain structure. Higher rates of soft neurological signs (both motor and sensory) were associated with a reduction of grey matter volume of subcortical structures (putamen, globus pallidus and thalamus). Signs of sensory integration deficits were additionally associated with volume reduction in the cerebral cortex, including the precentral, superior and middle temporal, and lingual gyri. Neurological soft signs and their associated brain changes were independent of antipsychotic exposure. We conclude that neurological soft signs are associated with regional grey matter volume changes and that they may represent a clinical sign of the perturbed cortical-subcortical connectivity that putatively underlies psychotic disorders(AU)

Malignant meningioma with extension into the neck

One per cent of all brain tumours and twenty per cent of meningiomas eventually develop an extracranial extension. The least common site is the neck. We report a case of malignant meningioma with extension into the neck of a 39-year-old male.(Au)

Filariasis of the ankle: magnetic resonance imaging

Filariasis is a world health problem that is frequently seen in tropical and subtropical countries. In endemic areas, the clinical spectrum of extremity swelling, lymphangitis, or elephantiasis is usually recognized as filariasis. In the United States, diagnosis of the disease may be more difficult because of lack of familiarity with this infection. We present a case of filaremic anthropathy of the ankle joint and the magnetic resonance imaging (MRI) findings of this disease. It is the first reported case of MRI findings in a human patient. MRI has been done on animal models with filariasis, and the findings are similar. (AU)

Afro-Caribbean and Asian Subjects living in the UK may be susceptible to atypical Parkinsonism

INTRODUCTION: Although the prevalence and pattern of parkinsonism in white caucasian population have been reported, little is known about the pattern and prevalence of parkinsonism in black and Asian patients (from the Indian subcontinent). We recently reviewed this topic and felt that contrary to popular belief parkinsonism may be commoner in UK. Furthermore, the pattern of parkinsonism appears to be different in this group. METHODS AND RESULTS: Based on this observation we have now set up a worldwide and British study involving Afro-Caribbean and India (patients originating from the Indian subcontinent) subjects. In the first leg of this study, we carried out a door to door knocking assessment for Parkinsonism in one electoral ward in London with a high Afro-Caribbean population and identified three cases of atypical parkinsonism. We have subsequently been reviewing the case files of over 150 patients attending Movement Disorders clinical in areas of London with a high population of the Afro-Caribbean and Indian population. So far, we have identified 18 cases of Parkinsonism in patients of Afro-Caribbean and Asian origin. Fourteen out of 18 cases show non familial atypical parkinsonism with signs of progressive supranuclear palsy in five, probable striato nigral degeneration in four, and a levodopa unresponsive progressive parkinsonism which falls but no dystonia in three, spino-cerebellar atrophy type three in one and autopsy proven Pick's disease in 1.4. High field Magnetic resonance imaging and CT brain scanning have been remarkable apart from non-specific cortical atrophy and signs of vascular disease in some. CONCLUSIONS: Our observations suggest that parkinsonism is probably more common than realized in the Afro-Caribbean and Asian populations and these patients may be more susceptible to atypical parkinsonism. The reason for this is unclear and may reflect genetic or environmental factors as has been postulated in relation to higher incidence of diabetes and ischaemic heart disease in migrant Asian population in UK. Further epidemiological studies addressing this issue are in progress. (AU)

Transcaheter uterine artery embolisation to treat large uterine fibroids with MRI quantitative assessment

Fibroids are benign tumours of the uterus which occur more commonly and earlier in black women. We do not know what causes the fibroids to grow, but their growth seems to be hormone dependant. Some women may have asymptomatic fibroids and be unaware of their presence. However, many others seek help from gynaecologists due to menorrhagia, sometimes leading to anaemia and pressure symptoms leading to pain, sciatica, urinary infrequency and constipation. Fibroids may also contribute towards infertility and cause problems in pregnancy. Treatment of fibroids is notoriously difficult. Drug treatment has proved unsuccessful in the long term treatment of fibroids and has been reserved for preoperative treatment. Myomectomy is a difficult operation for women which may require blood transfusions, unacceptable to Jehovah's Witnesses and rarely lead to hysterectomy due to uncontrollable bleeding. Women above child bearing age are usualy offered hysterectomy, but many women are unhappy to loose their uterus as this has cultural and social implications. At St. Thomas' and Guy's Hospital we have pioneered a new treatment for fibroids whereby the uterine arteries are embolised bilaterally and by cutting off the blood supply to the fibroids, they shrink in size and degenerate. An interventional radiologist inserts a catheter into the femoral artery in the groin and passes a guide wire under x-ray control into the uterine artery. Non-biodegradable particles are introduced into the artery until flow is reduced or stopped. This is repeated on the second side. The procedure is performed under sedation and takes about an hour. The patients are admitted for 24-36 hours for analgesia. Ten women have been treated to date, nine were Afro-Caribbean and we have three month follow-up on eight. MRI scans were performed before the procedure and at three months to obtain quantitative assessment of reduction in volume. The uterine volume reduced by a mean of 51 percent and further shrinkage is expected. All but one of the patients noticed improvement in one or all of their symptoms. Patient satisfaction was high. The main side effects of the procedure were pain, controlled with simple analgesia and vaginal discharge. This seems a good treatment for women with symptomatic fibroids who are not suitable for or unwilling to undergo surgery. It avoids a general anaesthetic major surgery and blood transfusions. The procedure is tolerated well and has good symptomatic cure rates.(AU)

Multiple scherosis, tropical spastic paraparesis and HTLV-1 infection in Afro-Caribbean patients in the United Kingdom

Forty four consecutive patients of Afro-Caribbean origin resident in the United Kingdom (UK) were studied, based on a provisional diagnosis of myelopathy of unknown cause, tropical spastic paraparesis (TSP) or multiple scherosis (MS). Of 30 patients with progressive paraparesis 27 had serum antibodies to HTLV-1 and were classified as having TSP. Fourteen patients fulfilled the criteria for MS and none of 12 tested had HTLV-1 antibodies. All the TSP patients and nine of those with MS were born in West Indies. Five of the West Indian born MS patients had migrated to the UK after adolescence but the duration of residents in the UK before symptoms of MS developed was similar to those born in the UK (average 18 years). The features that differentiated MS from TSP patients, apart from HTLV-1 status, included clinical evidence of cranial nerve involvement, more extensive abnormalities on the brain and cervical cord MRI and asymmetry of the VEP latency increase, all of which were more frequent in the MS group. Of the three patients without a diagnosis one, born in the UK, had marked abnormalities on MRI of the brain indistinguishable from those seen in MS (AU)

Computerised axial tomography and magnetic resonance imaging bridging the gap - abstract

Since 1983, computerised axial tomography (CAT) has been the mainstay of neurological imaging in Trinidad and Tobago. In 1988, magnetic resonance imaging (MRI) became available in nearby South America. This study was done to examine the capabilities, limitations and pitfalls of CAT scanning and to provide guidelines for patients referral for MRI. The most recent 2,000 head and 68 body CAT scans performed from 1984 to 1988 were reviewed. Abnormalities were seen in 759 (38 percent) of head scans: tumours 262 (34.5 percent), cerebral atrophy 128 (17 percent), ischaemic infarcts 121 (16 percent), intracranial haemorrhage 105 (14 percent), hydrocephalus 42 (5.5 percent), traumatic cerebral contusions 40 (5 percent), infection 36 (5 percent) and vascular malformations 14 (2 percent). Abnormalities were seen in 45 (66 percent) body scans: spinal lesions 20 (44 percent), and lesions of the pancreas 8, liver 8, kidneys 4, adrenals 2, and 1 each in the lung, oesophagus and spleen. CAT scanning, however, was sometimes unable to resolve diagnostic dilemmas, and in 1988, 32 patients were referred for 22 head and 10 spine MRI studies. MRI head abnormalities were tumours 4, absceses 3 (1 in the brain stem), and 1 each of subdural haematoma, demyelinating disease and hydrocephalus. There were 12 normal head MRI studies. MRI spine abnormalities (7) were lumbar disc herination, cervical spondylosis 2, and syringomyelia 1, and 3 studies were normal. CAT scan limitations were most apparent with bone artefacts in the posterior and temporal fossae and the pituitary region, isodense subdural collections, differentiating enhancing infarcts from tumour and in demyelinating disease. MRI did not have these limitations and had the advantage of direct multiplanar (coronal and sagittal) imaging, superior tissue type differentiation, no ionizing radiation or allergenic contrast media. MRI is especially useful in imaging pituitary, parasellar and brain stem lesions, the spine and spinal cord, the heart, abdominal viscera, and joints. Its realtive disadvantages include slower scan times, danger to patients with indwelling ferromagnetic material, claustrophobia and higher equipment cost (AU)