Post-stroke aggressive behavior in patients with first-ever ischemic stroke: underlying clinical and imaging factors.

BACKGROUND: Aggression is defined as a complex behavior consisting of a combination of sensory, emotional, cognitive and motor elements. We aimed to examine the relationships between post-stroke aggressive behavior (PSAB) and neuropsychological and neuroimaging findings. METHODS: 380 patients in the stroke unit were classified as aggressive or non-aggressive based on symptoms elicited by the Neuropsychiatric Inventory (NPI) and aggression screening questionnaire. RESULTS: Aggressive behavior was detected in 42 (11.1%) of 380 patients who had a first ischemic stroke. Patients with PSAB were older than those without (338 patients) (66.98 + 13.68 vs. 62.61 + 13.06, P = 0.043). Hamilton depression and anxiety scales showed significantly higher rates of depression and anxiety in the PSAB group compared to the non-PSAB group (47.6% vs. 16.3% and 57.1% vs. 15.4%, respectively; P = 0.001). Lesion mapping analysis showed that lesions in patients with PSAB mostly included the lower parietal lobe and lateral frontal gyrus. Multiple regression analysis showed that gender (OR, 2.81; CI%, 1.24-6.39), lateral prefrontal infarction (OR, 6.43; CI%, 1.51-27.44), parietal infarction (OR, 2.98; CI%, 1.15-7.76), occipital infarction (OR, 2.84; CI%, 1.00-8.06), multiple infarcts (OR, 5.62; CI%, 2.27-13.93), anxiety (OR, 2.06; CI%, 0.89-4.81) and verbal memory deficit (OR, 4.21; CI%, 1.37-12.93) were significant independent predictors of PSAB. CONCLUSION: The presence of PSAB may be related to neuropsychiatric symptoms such as high anxiety and verbal memory impairment, and neuroanatomical location of the lesions.

Prognostic Factors For Functional Outcome in Patients with Mesencephalic Hemorrhage.

Introduction: Mesencephalic hemorrhage (MH) is a rare presentation of spontaneous intraparenchymal hemorrhage. This study aims to evaluate prognostic parameters of the MH outcome. Methods: We conducted an extensive search in the literature for cases with spontaneous, isolated mesencephalic hemorrhage. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Sixty-two eligible cases have been reported in the literature as proven by CT or MRI, and to these, we added six cases confirmed by MRI. The modified Rankin Scale (mRS) was dichotomized into two groups as the favorable outcome (FO; score, 0-2) and unfavorable outcome (UO; score, 3-6). Results: Of the 68 patients studied, 26 (38%) presented with normal consciousness, 22 (32%) with lethargy , and 20 (29%) with stupor or coma. There was no cause of hemorrhage in 26 (65%) patients with FO and 12 (43%) with UO (p=0.059). In univariate analyses, neither arteriovenous malformations (p=0.33) nor cavernomas (p=0.19) were associated with outcome. Multiple logistic regression analysis revealed that hypertension (OR, 51.22; CI95%, 1.92-1370.24; P=0.019), consciousness (OR, 133.54; CI95%, 1.61-1113.3; P=0.03), NIHSS at admission (OR, 57.23; CI95%, 2.87-1141.2; p=0.008), and ventrodorsal hemorrhage size (≥1 cm) (OR, 61.83; CI95%, 2.15-1779.2; p=0.016) were significantly associated with UO. Three months after stroke, 40 patients (59%) had FO, 28 (41%) had UO, and 8 (12%) died. Conclusion: These results suggest that ventrodorsal size of hemorrhage and clinical severity at stroke onset are possible predictors of functional outcome after mesencephalic hemorrhage.

A Neuropsychiatric and Neuroimaging Study of Unilateral and Bilateral Striatal Ischemic Lesions.

OBJECTIVE: Neuropsychiatric disorders after striatal territory stroke have not been studied systematically. The investigators aimed to study the spectrum of cognitive and behavioral disorders following striatal infarcts. METHODS: Different aspects of cognitive functions, including executive, frontal lobe, memory, visuospatial, language, and semantic processing, were assessed among patients with striatal infarct. Structural MRI data sets were obtained 3 months after stroke to delineate affected territories of the striatum. MRIcroGL software was used to acquire multiple layers of images, generate volume renderings, and draw volumes of interest. To determine the brain locus most frequently affected in patients with distinct cognitive disorders, ischemic area distributions in patients with cognitive dysfunction versus those without cognitive impairment were contrasted. RESULTS: Among 60 patients in this study, six different striatal infarction types were significantly associated with seven different cognitive categories (p<0.001). Unilateral caudate lesion was characterized by attention, planning, and executive disorders (38%), and unilateral lentiform infarct was characterized by executive (36%) and frontal (36%) dysfunctions. Bilateral caudate infarcts caused impairments in frontal and executive functions (75%), as well as in autobiographical (50%) and episodic (50%) memory. In those with bilateral caudate plus lentiform infarcts, all components of frontal and executive functions were dramatically impaired. The anteromedial striatum was affected more frequently in patients with language impairment compared with patients with other types of cognitive dysfunction (p<0.001). CONCLUSIONS: Following striatal stroke, a wide range of frontal-like cognitive impairments occurred, along with impaired working memory, declarative memory, executive function, speech fluency, and motor function.

Cognitive and Behavioral Disorders in Patients with Superior Parietal Lobule Infarcts.

BACKGROUND/OBJECTIVE: The superior parietal lobule (SPL) plays a strategic role in somatosensory and visuomotor integration. This study aims to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated SPL stroke. METHODS: We assessed neuropsychological and behavioral findings in 14 patients with isolated SPL stroke among 4200 patients with ischemic stroke. All patients underwent neuroimaging, clinical and neuropsychological assessment after stroke. RESULTS: Of the 14 patients enrolled, the first complaints were tactile and visuospatial disorders at stroke onset. Except for 6 patients with only 1 cognitive impairment, the majority of patients (57%) experienced more than 1 cognitive impairment category. Functional hemispheric asymmetries have been found in different cognitive processes, such as between visuospatial and body image functions and language process. Among visuospatial abilities disorders, spatial disorientation, visuospatial neglect, and visual extinction were found in two-thirds (63%) of patients with right SPL lesion. Body schema and image disorders were observed in all patients with right-sided lesions, such as alien hand, autotopagnosia for body parts (36%), autotopagnosia for sensory sensations (36%), and fading limb (21%). Two-thirds (57%) of patients with left SPL had impairment in language abilities. CONCLUSION: Our findings after stroke suggest that SPL plays a pivotal role in the regulation of visuospatial abilities, body schema and body image processing, and language skills through bilateral frontoparietal networks and interhemispheric parietal networks.

Efficacy of citalopram on stroke recurrence: A randomized clinical trial.

Post-stroke depression is one of the main causes of cerebrovascular and cardiovascular diseases. The aim of the present study was to investigate the efficacy of citalopram on stroke recurrence. A 52-week, randomized, double-blind, studyinvolved 440 ischemic stroke patients with depression. Patients with depression who met depression criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and V) and Hamilton Depression Rating Scale ≥ 8 (HAM-DRS) were dichotomized into patients receiving citalopram (225 patients), titrated according to clinical response, and patients with placebo (215 patients) for 52 weeks. The primary outcome measure was stroke recurrence and the secondary outcome measures were cardiovascular events and mortality. Stroke recurrence (66% vs 34%; P = 0.001) and cardiovascular events (76% vs. 24%; P = o.oo1) were significantly higher in the placebo group compared to those treated with citalopram. Multivariable analysis showed that hypertension, atrial fibrillation, and large-artery disease were significantly associated with stroke recurrence. Executive processing disorder was more associated with stroke recurrence than other neuropsychological disorders (OR, 1.74; CI95%, 1.04-2.89; P = 0.035). Survival analysis showed that treatment for depression interacted with time to reduce stroke recurrence by nearly half (39% vs. 61%; P = 0.05). The current study supports the importance of depression treatment in protecting the patients from recurrent strokes. This result warrants further studies to demonstrate the efficacy of depression treatment on stroke recurrence.

Exploring Cognitive Impairment in Patients With Bilateral Capsular Genu Lesions.

OBJECTIVE: The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored. METHODS: An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018. RESULTS: Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke. CONCLUSIONS: Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.

Invisible doppelgänger and body image disorders in right superior parietal lobule stroke, a case series.

Autoscopic phenomena or an "invisible doppelgänger" refer to the illusory reduplication of one's own body. Body image disorder involves distorted perception or decreased body awareness. In the literature, feeling of presence (FOP) is rarely presented with a circumscribed cerebral pathology due to acute vascular lesions, and concomitant FOP and disorders of the body image or the body schema (BIBS) have rarely been reported. We present three cases of both FOP and BIBS disorders. All patients reported the two types of symptoms almost simultaneously: The first patient had the symptom of somatoparaphrenia characterized by deny ownership of the hand and feeling that it does not belong to her, the second patient had the sign of fading limb presented with misuse of his left hand when it was not under visual control and could not mentally represent and locate this part of the body in space, and the third patient had autotopagnosia; he was unable to localize any touched area below the elbow and knee. All patients had right parietal ischemic lesions involving the superior parietal lobule, and two patients had an adjacent additional precuneal involvement. Based on the cases presented here, it is plausible that BIBS may develop in addition to FOP, especially in lesions involving the superior parietal lobule and precuneus.

The Clinical and Cognitive Spectrum of Artery of Percheron Infarction: 1-Year Follow-Up.

OBJECTIVE: Survivors of patients with artery of Percheron infarction (API) often have a prolonged and disabling form of cognitive impairment that remains insufficiently characterized. We aimed to examine the clinical and cognitive features of API in the short and long term after stroke. METHODS: We reviewed 6400 patients with a first-ever stroke included in the Stroke Registry between 2011 and 2021. The diagnosis of API was based on clinical diagnosis and imaging confirmation. All patients underwent neuropsychological assessment at hospital stay and 1 year after stroke. A z-score of each patients' cognitive test point was calculated, and a z-score inferior to 2 was considered as pathological. RESULTS: Of the 10 patients enrolled, all had cognitive impairment, consciousness, and behavioral disorders at stroke onset. Six patients had pure bilateral thalamic involvement while four had bilateral thalamic and rostral midbrain involvement. At 12 months, 50% of patients had global mental state scores 2 SD below the population mean (z-score mean ± SD, -2.17 ± 0.4). Most of the prefrontal cortex cognitive processes including executive functions such as planning and cognitive control (z-score mean ± SD, -3.92 ± 0.3), processing speed (-4.42 ± 0.5), working memory (-3.97 ± 0.3) were severely impaired at stroke onset. Especially in patients with thalamic and rostral midbrain involvement, deficiencies in executive function (z-score mean ± SD, -2.60 ± 0.4), processing speed (-2.22 ± 0.5), working (-3.76 ± 0.4), and episodic memory (-2.23 ± 0.3) continued 12 months after stroke. CONCLUSIONS: The occlusion of the artery of Percheron results in severe behavioral and cognitive disorders in the short and long term after stroke.

The clinical and cognitive spectrum of locked-in syndrome: 1-year follow-up of 100 patients.

In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive functions are preserved and it is not known exactly how much it has improved. We aimed to examine the clinical and cognitive features of LIS 1 year after stroke. One hundred patients with locked-in syndrome (LIS) were recruited between January 2008 and May 2019 among 8200 patients with ischemic stroke. Patients were classified into two groups as single pontine infarcts (n = 72), and pontine plus multiple ischemic lesions (PMIL) (n = 28). Since the patients had limited motor and verbal response, the cognitive status of the patients in the early and late stages was evaluated with the Short Neuropsychological Questionnaire for Disabled Patients (SNQDP) test. At the onset of stroke, orientation to time and place was normal in 43% of patients with a single infarct compared with 18% of those with PMIL (OR 3.48; 95% CI 1.10-10.18; P = 0.015). There was no sustained visual fixation or tracking in 53% of patients with a single pontine infarct and 82% of those with PMIL (OR 4.12; 95% CI 1.41-12.02; P = 0.005). After 1-year follow-up, there was significant difference between patients with a single infarct and those with PMIL regarding to perception and execution, especially complex command follow (P = 0.042), attention span and concentration (P = 0.30), intelligible verbalization (P = 0.022). There was relatively high incidence (24%) of patients with a "good outcome" (mRS = 3) in those with single infarct. Given as in our study that many patients can show significant improvement in LIS, we recommend aggressive supportive measures, intense physical, speech and cognitive therapy to facilitate interaction with others and the environment.

Variants of Avellis Syndrome Due to Medulla Oblongata Infarction: A Case Series.

INTRODUCTION: Avellis syndrome is classically defined as a neurological disorder characterized by paralysis of the soft palate and vocal cords on one side, and a loss of sensation of pain and temperature sense on the other side. Between 2010 and 2020, 5400 patients with ischemic stroke were admitted to the Stroke Unit and prospectively entered in our Stroke Registry. CASE REPORT: A total of 216 patients with magnetic resonance imaging-proven ischemic lesions restricted to the medulla oblongata were identified. Among them, 5 patients had Avellis syndrome with a small medullary infarction. There was paralysis of the soft palate and vocal cords in all patients, but besides of loss of pain sensation and temperature sense, there were also partial disturbances in position and vibration senses in 3 patients. Different types of neuro-ophthalmologic findings were observed in 4 patients. In 5 patients, the cause of medulla oblongata infarct was microscopic polyangiitis vasculitis, neuro-Behçet disease, vertebral artery dissection, small vessel disease, and neurobrucellosis small vessel vasculitis. CONCLUSIONS: Avellis syndrome may present with additional neurological findings besides its classic definition. Apart from atherosclerotic disease, rare causes should be investigated in detail in small ischemic medullary lesions.

Cognitive and Behavioral Disorders in Patients with Precuneal Infarcts.

OBJECTIVE: Ischemic stroke of the precuneal cortex (PC) alone is extremely rare. This study aimed to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated PC infarcts. METHODS: We assessed neuropsychological and behavioral findings in 12 patients with isolated PC infarct among 3,800 patients with ischemic stroke. To determine the most frequently affected brain locus in patients, we first overlapped the ischemic area of patients with specific cognitive disorders and patients without specific cognitive disorders. Second, we compared both overlap maps using the "subtraction plot" function of MRIcroGL. RESULTS: Patients showed various types of cognitive disorders. All patients experienced more than 1 category of cognitive disorder, except for 2 patients with only 1 cognitive disorder. Lesion topographical analysis showed that damage within the anterior precuneal region might lead to consciousness disorders (25%), self-processing impairment (42%), visuospatial disorders (58%), and lesions in the posterior precuneal region caused episodic and semantic memory impairment (33%). The whole precuneus is involved in at least one body awareness disorder. The cause of stroke was cardioembolism in 5 patients (42%), large artery disease in 3 (25%), and unknown in 4 (33%). CONCLUSIONS: This study showed a wide variety of neuropsychological and behavioral disorders in patients with precuneal infarct. Future studies are needed to achieve a proper definition of the function of the precuneus in relation to the extended cortical areas. PC region infarcts have been found to predict a source of embolism from the large arteries or heart.

Surgical Decompression for Space-Occupying Hemispheric Infarction: A Systematic Review and Individual Patient Meta-analysis of Randomized Clinical Trials.

Importance: In patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups. Objective: To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics. Data Sources: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction. Study Selection: Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected. Data Extraction and Synthesis: Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses. Main Outcomes and Measures: The primary outcome was a favorable outcome (modified Rankin Scale [mRS] score ≤3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score ≤4) and excellent (mRS score ≤2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories. Results: Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies. Conclusions and Relevance: The results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.

Associations Between Neuroanatomic Patterns of Cerebral Infarctions and Vascular Dementia.

OBJECTIVE: A history of multiple cerebral infarctions is generally regarded as an important risk factor for vascular dementia. The authors examined the risk of vascular dementia in patients with multiple acute ischemic lesions. METHODS: The authors conducted a hospital-based prospective study of 11,200 patients with first-time stroke who underwent 1.5 or 3-T MRI and a global cognitive assessment. Univariate and multivariate logistic regression analyses estimated the risk of dementia associated with multiple lesions versus a single lesion. RESULTS: Having multiple lesions, compared with having a single lesion, was significantly associated with dementia in patients with stroke (odds ratio=5.83, 95% CI=5.08, 6.70; p<0.001). The apoliproprotein ε4 allele was more frequent in patients with multiple lesions than in those with a single lesion (odds ratio=1.70, 95% CI=1.39, 2.07; p<0.001). Severe leukoaraiosis (odds ratio=15.77, 95% CI=8.38, 29.68; p<0.001) and microbleedings (odds ratio=1.31, 95% CI=1.06, 1.63; p<0.01) were strong confounders for dementia in the multivariate analysis. Multiple logistic regression analysis showed that multiple lesions in one hemisphere versus a single lesion (odds ratio=2.14, 95% CI=1.83, 2.51; p<0.001), involvement of strategic regions (odds ratio=4.73, 95% CI=4.07, 5.49; p<0.001), and stroke lesion volume (odds ratio=1.31, 95% CI=1.03, 1.66; p=0.03) were significantly associated with dementia. There was a preponderance of lesions on the left side in patients with dementia (odds ratio=2.56, 95% CI=2.11, 3.11; p<0.001). CONCLUSIONS: Multiple spontaneous anterior or posterior circulation lesions after stroke increase a patient's risk of developing dementia. Recognition of multiple ischemic lesions after stroke may allow targeted rapid therapeutic interventions to prevent subsequent cognitive deterioration.

Predictors of Outcome in Patients with Medullary Hemorrhage.

BACKGROUND: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage. METHODS: We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by ≥1 point in motor power, or ≥2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0-2 was presumed as favorable outcome (FO) and mRS 3-6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke. RESULTS: We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10-10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22-4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85-20.04; P = 0.09). The diameter of hemorrhage was significantly larger (≥1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87-148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13-21.94; P = 0.03). CONCLUSIONS: These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.

Cognitive functions in acute unilateral vestibular loss.

Cognitive deficits mainly involving visuospatial functions have been defined in patients with bilateral and even unilateral vestibular loss (UVL). We compared the cognitive test results of 21 patients with acute UVL with age- and education-matched healthy controls. The diagnosis of UVL was based on the clinical findings, a normal magnetic resonance imaging with diffusion-weighted sequence and canal paresis on the affected side on caloric testing. Cognitive tests assessing visuospatial functions (Benton's Judgment of Line Orientation test, Verbal and non-verbal Cancellation tests, Rey-Osterrieth Complex Figure test) and global mental status, verbal memory, learning, retention of information, and recalling (Mini Mental State Examination, Oktem Verbal Memory Process Test, Forward and Backward Digit span) were used in addition to Beck depression and Anxiety inventories. Abnormalities in verbal and non-verbal cancellation tests (p < 0.005), Benton's Judgment of Line Orientation test (p = 0.042) and backward digit span (p = 0.029) was found. A very prominent difference regarding Beck depression (p = 0.012) and anxiety inventories (p < 0.001) was present. On multiple regression analysis, the abovementioned cognitive tests' results lost their statistical significance (p > 0.05) when depression and anxiety scores were taken into consideration. The severity of canal paresis was found to be correlated with Benton's Judgment of Line Orientation test (p = 0.008, r = - 0.5639) and Rey-Osterrieth Complex Figure test copying scores (p = 0.029, r = - 0.477). Comparison of all the results in right- and left-sided lesions did not reveal a significant difference (p > 0.05). Vestibular patients are prone to develop anxiety, and depression. Deficits in visuospatial functions, mental manipulation, psychomotor speed and short-term memory detected in our patients with acute UVL seem to be enhanced by accompanying anxiety and depression. The extent of vestibular dysfunction was correlated with the severity of deficits in visuospatial skills. Lesion side did not cause alterations in cognitive or emotional status.

Cingulate infarction: A neuropsychological and neuroimaging study.

BACKGROUND AND PURPOSE: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, restricting human lesion/behavioural change correlational analysis. The aim of this study was to determine clinical, neuropsychological and neuroimaging features of isolated cingulate infarcts. METHODS: We studied, 3800 patients with first-ever ischemic stroke included in our Stroke Registry between 2012 and 2018. Among them we studied 7 patients with an acute isolated cingulate infarct confirmed by MRI. RESULTS: Among all patients, 7 patients (0.01%) showed ischemic lesions in the territory of cingulate cortex territory, allowing us to delineate 2 substantial distributions; (1) Anterior cingulate cortex (ACC) infarction (4 patients [57%]) was presented low vigilance level with apathy, mutism, deficits in executive function, attention, and disturbances of working, episodic and verbal memory; (2) Posterior cingulate cortex (PCC) infarction (3 patients [43%]) developed topographic disorientation, visual memory deficit and affective-emotional behavioural changes. CONCLUSIONS: According rarely seen CC infarction events, we suggest that anterior and posterior CC are functionally separated and differences in clinical presentation are explained by considering; ACC plays a role in executive functions, episodic and working memory, set maintenance, and PCC is focused on spatial and verbal attention, and memory system. We considered that different patterns of cingulate infarcts are the result of variation in cingulate arterial supply or suggest a source of embolism.

Genetic factors associated with the predisposition to late onset Alzheimer's disease.

BACKGROUND: Alzheimer's disease is a progressive, irreversible neurodegenerative disorder characterized by loss of memory and cognitive skills. More than 90% of cases are sporadic and have later age of onset. Many studies have shown a genetic predisposition for late onset Alzheimer's disease (LOAD). The most studied genetic predisposition factor is apolipoprotein E gene besides other susceptibility genes involved in vascular pathologies, homocysteine metabolism, and neuronal growth and differentiation such as methylenetetrahydrofolate reductase (MTHFR), angiotensin-converting enzyme (ACE), APOB and brain derived neurotrophic factor (BDNF). METHODS: In this study Factor V Leiden (G1691A) and H1299R, prothrombin G20210A, Factor XIII V34L, B-fibrinogen -455G>A, PAI-1 5G/4G, HPA1 b/a, MTHFR C677T, MTHFR A1298C, APOE, ACE I/D, BDNF C270T and G196A polymorphisms were evaluated in 100 LOAD patients and 100 age matched healthy controls. RESULTS: APOE4 allele, MTHFR CCA1298C and BDNF TTC270T genotypes were significantly higher in LOAD patients compared to the control group (p < 0.001, p = 0.04, p = 0.03, respectively). There were no significant associations between other genotypes and allele frequencies. Mini-Mental State Examination (MMSE) scores and age at onset of the patients were also evaluated for each and combined genotypes. Age at onset was significantly lowered by about approximately 4 and 5 years in patients carrying BDNF TTC270T and MTHFR TTC677T genotypes, respectively. CONCLUSION: APOE, MTHFR A1298C and BDNF C270T polymorphisms may be associated with LOAD and BDNF and MTHFR alleles may play a role in the age at onset of the LOAD.

Major neurocognitive disorder following isolated hippocampal ischemic lesions.

BACKGROUND AND PURPOSE: Major cognitive disorder (MND) following vascular events is known as second causes of dementia after Alzheimer's disease (AD). Acute onset MND due to isolated hippocampal infarction has not been recognized as a specific subtype of vascular dementia, and there is no validated criteria for the identification of such cases, either clinically or radiologically. RESULTS: Among 7200 patients with first-ever ischemic stroke, 22 patients (0.3%) showed acute isolated ischemic lesions in the hippocampus. Four of them presented acute MND characterized by confusion at the beginning of stroke and thereafter they developed typical clinical characteristics of MND. These cases allowed us to delineate a specific type of dementia characterized by confusion at stroke onset, dull and aimless appearance, verbal and visual immediate or delayed memory deficits, dysexecutive syndrome. Major cognitive disorder was developed due to anterior involvement of the hippocampus with little interindividual variation. Stroke mechanism was artery-to-artery embolism or cardioembolism which can explain isolated infarcts of the hippocampus. CONCLUSIONS: Hippocampal MND generally occurred in acute bilateral isolated hippocampal infarcts. The clinical characteristic of MND may be secondary to lesions of the body of the hippocampus and interruption of the hippocampo-temporal pathways and cortical projections.