Serotonergic correlation with anger and aggressive behavior in acute stroke patients: an intensity dependence of auditory evoked potentials (IDAP) study.

Anger and aggressive behavior (AB) are two of the main post-stroke behavioral manifestations, which could imply both an anger trait (TA) or a state condition of anger (SA). Serotonergic system is thought to play an inhibitory control on aggressive impulse. Nevertheless, whether 5HT has the same role in TA and in SA, is still debated. Intensity dependence of auditory evoked potentials (IDAP) is thought to be inversely related to the central 5HT tone. The aim of this study was to evaluate, in acute stroke patients, the 5HT system involvement in AB by IDAP. Consecutive stroke patients were evaluated and compared with healthy controls. The Spielberger Trait Anger Scale (STAS) was used to assess AB, SA and TA. Patients with AB and TA showed a significantly increased IDAP value, whereas patients with SA had a significantly lower IDAP; this indicates an increased 5HT tone. In acute stroke patients with AB, there is a decreased central 5HT tone. Surprisingly, we found an opposite 5HT feature between patients with TA and those showing SA, suggesting that the hypothesis of aggression based on 5HT deficiency requires further investigations. This might open new strategies in the treatment of post-stroke AB.

Familial Alzheimer's disease sustained by presenilin 2 mutations: systematic review of literature and genotype-phenotype correlation.

Familial Alzheimer's disease (FAD), despite representing a rare condition, is attracting a growing interest in the scientific community. Improved phenotyping of FAD cases may have a relevant impact both in clinical and research contexts. We performed a systematic review of studies describing the phenotypic features of FAD cases sustained by PSEN2 mutations, the less common cause of monogenic AD. Special attention was given to the clinical manifestations as well as to the main findings coming from the most commonly and widely adopted diagnostic procedures. Basing on the collected data, we also attempted to conduct a genotype-phenotype correlation analysis. Overall, the mutations involving the PSEN2 gene represent an extremely rare cause of FAD, having been reported to date in less than 200 cases. They are mainly associated, despite some peculiar and heterogeneous features, to a typical AD phenotype. Nevertheless, the frequent occurrence of psychotic symptoms may represent a potential distinctive element. The scarcity of available phenotypic descriptions strongly limits the implementation of genotype-phenotype correlations.

Rivastigmine in the treatment of hypersexuality in Alzheimer disease.

Inappropriate sexual behaviors (ISB) represent uncommon and often misdiagnosed clinical disorders among patients with Alzheimer disease. So far, no randomized clinical trials regarding the treatment of ISB in demented people have been conducted, but available data from case series and isolated case reports suggest the efficacy of selective serotonin reuptake inhibitors (SSRIs), antipsychotics, antiandrogens, and H2-receptor antagonists. Controversial data exist on the therapeutic influence of cholinesterase inhibitors on sexual disorders. In the present article, we describe the case of an Alzheimer disease patient presenting hypersexuality, successfully treated with rivastigmine. Thus, we perform a revision of the existing literature regarding the therapeutical effect of cholinesterase inhibitors in the treatment of ISB.

Attachment models affect brain responses in areas related to emotions and empathy in nulliparous women.

BACKGROUND: The attachment model, as assessed by means of the Adult Attachment Interview (AAI), is crucial for understanding emotion regulation and feelings of security in human interactions as well as for the construction of the caregiving system. The caregiving system is a set of representations about affiliative behaviors, guided by sensitivity and empathy, and is fully mature in young-adulthood. Here, we examine how different attachment models influence brain responses in areas related to empathy and emotions in young-adult subjects with secure and dismissing attachment models. METHODS: By means of AAI, we selected 11 nulliparous young-adult females with a secure model and 12 with a dismissing model. Subjects underwent functional magnetic resonance, whereas imitating or observing and empathizing with infant facial expressions. Subjects were tested for alexithymia and reflective functioning. RESULTS: Dismissing subjects activated motor, mirror, and limbic brain areas to a significantly greater extent, but deactivated the medial orbitofrontal cortex (mOFC) and the perigenual anterior cingulated cortex (pACC). During emotional faces, increased activity in dismissing women was seen in the right temporal pole. Furthermore, greater alexithymia was correlated with greater activity in the entorhinal cortex and greater deactivation in the pACC/mOFC. CONCLUSIONS: These findings provide evidence of how the attachment model influences brain responses during a task eliciting attachment. In particular, hyperactivation of limbic and mirror areas may reflect emotional dysregulation of infantile experiences of rejection and lack of protection, whereas increased deactivation of fronto-medial areas may be the expression of the inhibition of attachment behaviors, which is a typical aspect of dismissing attachment.

Presenilin 2 mutation R71W in an Italian early-onset sporadic Alzheimer's disease case.

Mutations in the presenilin 2 (PSEN2) gene are less commonly identified as genetic causes of early-onset familial Alzheimer's disease than mutations in the amyloid precursor protein (APP) and the presenilin 1 (PSEN1) genes. In fact, only 23 different mutations in the PSEN2 gene have been described in the literature. This paper deals with a sporadic case of a 55 year-old subject bearing an amino acid substitution from arginine to tryptophan at codon 71 of PSEN2 and presenting a peculiar early-onset Alzheimer's disease phenotype.

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report.

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.

Extracranial and intracranial sonographic findings in vertebral artery diseases.

OBJECTIVE: The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases. METHODS: We conducted a review of sonographic findings in VA diseases. RESULTS: Various VA diseases are described, and sonographic techniques and features are discussed. CONCLUSIONS: Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra-arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real-time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation.

Noninvasive imaging of carotid arteries in stroke: emerging value of real-time high-resolution sonography in carotid occlusion due to cardiac embolism.

OBJECTIVE: Comprehension of the pathophysiologic characteristics of atherosclerosis has focused its attention on the study of dynamic and metabolic processes involving the vessel wall as possible causes of stroke. When compared with conventional radiologic techniques, sonography has the main advantage of being a real-time imaging modality. We report 2 acute stroke cases in which carotid sonography showed some dynamic features that could not be identified with computed tomography (CT) and magnetic resonance angiography (MRA). METHODS: Carotid sonography with high-resolution probes (9-14 MHz) was compared with CT and MRA findings showing carotid axis occlusion in 2 patients with acute stroke. RESULTS: In case 1, the internal carotid artery occlusion observed on CT and MRA was interpreted as a dissection on a clinical basis, but sonography showed a mobile embolus originating from the heart in the internal carotid artery. In case 2, the occlusion of the whole carotid axis observed on CT and MRA was instead related to a heart-originating embolus floating in the common carotid artery. CONCLUSIONS: The evaluation of dynamic aspects of atherosclerosis is fundamental to understanding the pathophysiologic characteristics of stroke. Sonography is fundamental in carotid artery imaging for its possibility of showing dynamic processes that could be misdiagnosed with "static" imaging. The correct identification of the pathophysiologic characteristics of stroke in these cases could have led to different diagnostic and therapeutic algorithms.

A novel mutation in the predicted TMIII domain of the PSEN2 gene in an Italian pedigree with atypical Alzheimer's disease.

Alzheimer's disease (AD) is characterized by accumulation of toxic amyloid-beta (Abeta) in the brain, with neuronal death, and an associated increased Abeta(42/40) ratio. Several mutations in presenilin 1 (PSEN1), presenilin 2 (PSEN2), and amyloid-beta precursor protein are involved in the etiology of familial AD (FAD); these mutations alter the Abeta(42/40) ratio and promote apoptosis. We describe an Italian pedigree linked to a novel mutation (S175C) at the third transmembrane domain of PSEN2. Clinical phenotype in these individuals is characterized by fast cognitive decline with progressive memory impairment, early involvement of executive functions, behavioral disturbances, and extrapyramidal signs.

13th congress of the European Federation of neurological sciences.

The 13th Congress of the European Federation of Neurological Sciences (EFNS) was held in Florence and was open to neurologists and healthcare professionals interested in neurological disorders. The congress offered teaching courses and main topics. This article summarizes the highlights of some sessions of the 13th Congress of EFNS congress that may have clinical utility.

Imaging of carotid plaque angiogenesis.

Currently, characterization of the vulnerable plaque is a hot research topic as a more adequate strategy for preventing cerebrovascular events is being sought. Histological studies have recognized that plaque inflammation and the presence of adventitial vasa vasorum, intimal angiogenesis and plaque neovascularization are strong predictors of instability in atheromatous lesions of cerebrovascular and cardiovascular patients. The in vivo study of these features has been the focus of development of several new radiological imaging methods. Carotid ultrasound, with ultrasound contrast agents, is not only able to provide an enhanced assessment of the arterial lumen and plaque morphology with an improved resolution of the carotid intima-media thickness, but also to directly visualize adventitial vasa vasorum and plaque neovascularization. This technique and its future clinical implications are discussed in the present review.

Effect of citalopram in treating hypersexuality in an Alzheimer's disease case.

Hypersexuality in Alzheimer's disease (AD) has been rarely investigated. Hypersexual behaviours should be classified as a sexual obsession and included in the "obsessive-compulsive disorder-like" spectrum. Hypersexuality has no proven treatment, although reports have described reductions of this behaviour using antiandrogen treatment, H2-receptor antagonists and antipsychotic drugs. Serotonin reuptake blockers seem to be effective in the treatment of sexual obsessions or compulsions and less on paraphilic disturbances. We present the case of a 54-year-old male patient with Alzheimer's disease with compulsive sexual behaviour as reported by his wife. A 18-FDG PET scan evidenced prevalent hypometabolism of the right hemisphere, congruent with neuropsychological evaluation. Donepezil, 10 mg per day, produced cognitive improvement but no effects on sexual behaviour. Therapy with SSRI was subsequently started (citalopram): after 60 days, the patient showed improvement in both the compulsive pursuit of sex acts and the level of frustration when refused.

Contribution of right hemisphere to visual imagery: a visual working memory impairment?

Visual Imagery is the ability to generate mental images in the absence of perception, that is, We describe a patient, IM, who suffered from an acute ischemic stroke in the right anterior choroidal artery who appeared to demonstrate relatively isolated impairment in visual imagery. Her cognitive function, including her performance on tests of semantic function, was at ceiling, apart from a deficit in visual memory. IM failed in tasks involving degraded stimuli, object decision involving reality judgments on normal animals, and drawings from memory. By contrast, she was able to match objects seen from an unfamiliar viewpoint and to perform tasks of semantic and visual association. We hypothesize that IM has a visual working memory deficit that impairs her ability to generate full visual representations of objects given their names, individual feature, or partial representations. The deficit appears to be the result of damage to connections between the right thalamus and the right temporal lobe. Our findings may help to clarify the role of the thalamus in the cortical selective engagement processes that underlie working memory.

Sonographic carotid plaque morphologic characteristics and vascular risk factors: results from a population study.

OBJECTIVE: The role of vascular risk factors in atherosclerosis development is well established, whereas risk factors involved in determining plaque vulnerability are still a matter of debate. We investigated the vascular risk factor distribution in patients with carotid plaques. METHODS: We consecutively assessed sonographic plaque morphologic characteristics, the degree of stenosis, and the common carotid artery intima-media thickness (IMT) in 1655 patients. Demographic data, a documented history of symptomatic cerebrovascular disease (CVD), and the presence of vascular risk factors were collected. According to literature, heterogeneous hypoechoic plaques with an irregular surface or ulcerations and those with a severe degree of stenosis (>or=70%) have been considered "complex" plaques at "major" risk of stroke; homogeneous hyperechoic plaques with smooth surface lesions have been considered "simple" plaques at minor risk. RESULTS: Univariate analysis showed that all vascular risk factors were associated with the presence of carotid atherosclerotic lesions. Multiple logistic regression showed an independent association of hypertension and diabetes with complex plaques, which also had a thicker IMT. A history of CVD was observed more frequently in complex plaques, which had a higher stenosis percentage even after patients with a severe degree of stenosis (>or=70%) and indications for carotid surgery were excluded. CONCLUSIONS: Hypertension and diabetes are related to a thicker IMT and more severe complex plaques, which may reflect the instability of atherosclerotic process. Because two-thirds of the patients with complex plaques were asymptomatic for CVD, this raises the importance of surveillance sonography to monitor plaque evolution for prevention of symptomatic CVD.

Cerebral vasomotor reactivity is reduced in patients with erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED) is not only evidence of diffuse atherosclerosis but also an index of early endothelial damage. We investigated cerebrovascular reactivity, expression of early arterial damage, in patients with isolated ED (ED+) and controls (ED-). MATERIALS AND METHODS: Fifteen ED+ and 15 ED- subjects, matched for age (ED+: 58+/-6, ED-: 59 +/- 4 years) and vascular risk factors, were submitted to carotid duplex ultrasound and transcranial Doppler. Cerebrovascular reactivity was assessed on both middle cerebral arteries simultaneously calculating (a) the total vasomotor range (VMR) measured after breath holding and hyperventilation and (b) the rate of change (VMR/CO(2)) after breath holding. RESULTS: Carotid Duplex scanning showed a light carotid stenosis only in 3 (2 in the ED+ and 1 in the ED- group). No differences were observed in intima-media thickness between ED+ and ED-. Slightly slower mean middle cerebral artery flow velocities were observed in ED+ with respect to ED-. ED+ patients showed a reduced VMR (p < 0.001) and a slower VMR/CO(2) rate of change (p < 0.001) compared to ED-. CONCLUSIONS: The reduced reactivity in patients with isolated ED may represent a marker of early cerebral vasomotor dysfunction due to subclinical endothelial damage.