"This looks like a movie": a case report of post-surgical amnesia.

A 52-year-old male patient with a background of adaptive personality disorder was admitted for mitral valve repair and cardiac ablation for atrial fibrillation. He suffered intraoperative complications with severe mitral insufficiency that suffered ischemia.. Post-operatively, he demonstrated acute loss of retrograde autobiographical memory, prosopagnosia and a loss of public semantic memory. His CT scan was normal and MRI was not possible due to intra-cardiac leads. An initial diagnosis of hypoxic-ischemic encephalopathy was considered. A neuropsychological examination undertaken 20 days after his surgery showed a severe alteration of retrograde autobiographical memory, marked alteration of semantic knowledge and prosopagnosia. He demonstrated an average performance in tasks measuring constructional praxis, visuospatial ability, and executive functions. 34 days after surgery, and after a short nap, the patient "returns" to the day before admission and consequently recovers his memory. Repeat neuropsychological assessment demonstrated performance within the normal range across all previously tested domains. This sudden recovery of memory, together with a normal MRI, led to a rethinking of the diagnosis of dissociative amnesia. This case illustrates the long-standing discussion about the organic or functional origin of some memory disorders, in which, despite advances in neuroimaging techniques, it is still difficult to know their etiology .

Neuropsychological and neuropathological observations of a long-studied case of memory impairment.

We report neuropsychological and neuropathological findings for a patient (A.B.), who developed memory impairment after a cardiac arrest at age 39. A.B. was a clinical psychologist who, although unable to return to work, was an active participant in our neuropsychological studies for 24 y. He exhibited a moderately severe and circumscribed impairment in the formation of long-term, declarative memory (anterograde amnesia), together with temporally graded retrograde amnesia covering ∼5 y prior to the cardiac arrest. More remote memory for both facts and autobiographical events was intact. His neuropathology was extensive and involved the medial temporal lobe, the diencephalon, cerebral cortex, basal ganglia, and cerebellum. In the hippocampal formation, there was substantial cell loss in the CA1 and CA3 fields, the hilus of the dentate gyrus (with sparing of granule cells), and the entorhinal cortex. There was also cell loss in the CA2 field, but some remnants remained. The amygdala demonstrated substantial neuronal loss, particularly in its deep nuclei. In the thalamus, there was damage and atrophy of the anterior nuclear complex, the mediodorsal nucleus, and the pulvinar. There was also loss of cells in the medial and lateral mammillary nuclei in the hypothalamus. We suggest that the neuropathology resulted from two separate factors: the initial cardiac arrest (and respiratory distress) and the recurrent seizures that followed, which led to additional damage characteristic of temporal lobe epilepsy.

Prospective evaluation of first and last memory reports following moderate to severe traumatic brain injury.

Prospective monitoring of posttraumatic amnesia (PTA) status is recommended following traumatic brain injury (TBI). Use of patients' subjective reports is, however, still common and necessary in some circumstances. It is therefore important to understand how patients' self-reported first memories relate to prospective measures and how reliable these reports remain over time. In the present study, patients with moderate-severe TBI in PTA were asked about their first and last memories surrounding the injury daily and were administered the Westmead Post-Traumatic Amnesia Scale (WPTAS). Following PTA emergence, a semistructured interview was used to ascertain participants' reports of return of continuous memory after the injury, as well as their last preinjury memory. This interview was repeated six months later, along with the Community Integration Questionnaire to measure functional outcome and the Rey Auditory Verbal Learning Test to measure anterograde memory. The temporal order of recovery of WPTAS variables and subjective reports was determined, and consistency of subjective reports over time was examined using bivariate correlation and intraclass correlation coefficients (ICCs). Findings suggested that patients' reports of return of continuous memory aligned most closely with return of consistent orientation, and occurred significantly earlier than attainment of criterion on the WPTAS. Reported first memories were significantly later at follow-up (i.e., greater days post injury) and the ICC was not suggestive of adequate clinical reliability. Last memory reports were slightly more reliable, with 71% of cases remaining in the same band at follow-up. Demographic and injury-related variables were not significantly associated with the discrepancy between reports. The variability in patients' reports over time highlights the importance and value of prospective PTA monitoring.

Isolated Fornix Infarction with Damage to the Limbic System as a Cause of Persistent Amnesia: A Case Report.

BACKGROUND The fornix is a white matter tract bundle that acts as the major output of the hippocampus and is an important component of the Papez circuit. We present an instructive imaging case of sudden onset of persistent amnesia due to selective ischemic damage of the anterior fornix. CASE REPORT A 54-year-old Japanese male came to our attention for a sudden onset of retrograde amnesia, associated with severe anterograde amnesia. The brain magnetic resonance imaging demonstrated a bright diffusion restriction, which was associated with swollen fornices bilaterally. His symptoms gradually improved, but episodic memory impairment still persisted after 1 month. The coronal T1-weighted MPRAGE (magnetization-prepared rapid acquisition with gradient echo) sequence clearly showed disruption of the left anterior fornix. Diffusion tensor tracking showed decrease in the density of entire fiber tracts on the Papez circuit as well as location of the left fornix. CONCLUSIONS When dealing with sudden, persistent amnesia associated with small fornix infarction, it is prudent to consider the possibility of tract damage along with limbic system damage using MPRAGE sequence.

Validation of the 10-Item Orientation Questionnaire: A New Tool for Monitoring Post-Electroconvulsive Therapy Disorientation.

OBJECTIVES: Assessment of post-electroconvulsive therapy (ECT) disorientation at a single time point after ECT treatment may prove an effective and clinically useful method for monitoring the severity of disorientation and predicting ECT-induced retrograde amnesia. In this study, we aimed to validate a novel instrument (10-Item Orientation Questionnaire) developed to assess the level of disorientation after ECT. METHODS: Twenty-four depressed inpatients who were prescribed an acute course of ECT were administered the 10-Item Orientation Questionnaire at 30 minutes after ECT and had time to reorientation assessed at 3 time points after ECT (10, 30, and 60 minutes) at ECT treatments 1 to 3. The association between average performance of the 10-Item Orientation Questionnaire across the acute ECT course and retrograde amnesia at post-ECT was examined using the Autobiographical Memory Interview-Short Form. RESULTS: Mean performance on the 10-Item Orientation Questionnaire across treatments 1 to 3 was moderately correlated with average time to reorientation (r = -0.52, P = 0.02, n = 20). Across the acute ECT course, poorer performance on the 10-Item Orientation Questionnaire was associated with greater retrograde amnesia at post-ECT (r = 0.53, P = 0.03, n = 16). CONCLUSIONS: The 10-Item Orientation Questionnaire when administered at 30 minutes after ECT is sensitive for detecting patients with slow recovery of orientation after ECT. Use of this instrument therefore has potential for improving routine patient monitoring in clinical practice and identifying patients at increased risk of retrograde memory adverse effects following treatment.

Utility of Retrograde Amnesia Assessment Alone, Compared with Anterograde Amnesia Assessment in Determining Recovery After Traumatic Brain Injury: Prospective Cohort Study.

BACKGROUND: Posttraumatic amnesia (PTA) after traumatic brain injury (TBI) comprises anterograde amnesia (AA), disorientation, and retrograde amnesia (RA). However, RA is often neither assessed nor emphasized. A recent study demonstrated that although AA and disorientation were both present in non-TBI inpatients uniformly taking opioids, RA was absent. This suggests potentially significant utility with RA assessment alone since opioids are commonly prescribed post TBI. METHODS: We compared RA recovery with AA recovery in a prospective cohort post TBI. The Galveston Orientation and Amnesia Test (GOAT) represented a crude test for PTA (GOAT <75). AA was primarily assessed using the Westmead PTA Scale, and RA was assessed using the GOAT. All patients were prescribed oxycodone. RESULTS: Results were obtained (n = 31). While RA recovery coincided with a GOAT recovery in 19/31 (61%), AA recovery coincided with GOAT recovery in only 6/31 (19%), (χ2 = 11.5, P < 0.001). RA recovery preceded AA recovery in 15/31 (48%), while AA recovery preceded RA recovery in 7/31 (23%) (χ2 = 8.6, P = 0.003). Where RA recovery less frequently followed AA recovery, temporal lobe contusions were more frequent. RA recovery preceded/coincided with AA recovery in 100% of those who recovered when AA was defined as ×3 consecutive 12/12 scores (as is current widespread practice). AA recovery typically followed RA recovery with minimal delay. CONCLUSIONS: In the presence of potential in-hospital confounders including opioids, RA recovered significantly sooner after TBI than AA and was predictive of imminent AA recovery. RA assessment alone therefore had significant and novel utility in post-TBI assessment. RA assessment should be routinely recorded in all PTA assessment. Given its simplicity and resilience to common confounders, RA assessment should also be incorporated into the Glasgow Coma Scale.

What is the level of evidence for the amnestic effects of sedatives in pediatric patients? A systematic review and meta-analyses.

BACKGROUND: Studies have suggested that benzodiazepines are amnestic drug par excellence, but when taken together, what level of evidence do they generate? Are other sedatives as amnestic as benzodiazepines? The aim of this study was to assess the level of scientific evidence for the amnestic effect of sedatives in pediatric patients who undergo health procedures. METHODS: The literature was searched to identify randomized controlled trials that evaluated anterograde and retrograde amnesia in 1-19-year-olds who received sedative drugs during health procedures. Electronic databases, including PubMed, Scopus and Cochrane Library besides clinical trial registries and grey literature were searched. Two independent reviewers performed data extraction and risk of bias assessment using the Cochrane Collaboration's Tool. The meta-analyses were performed by calculating relative risk (RR) to 95% confidence intervals (CI). The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fifty-four studies were included (4,168 participants). A higher occurrence of anterograde amnesia was observed when benzodiazepines, the most well-studied sedatives (n = 47), were used than when placebo was used (n = 12) (RR = 3.10; 95% CI: 2.30-4.19, P<0.001; I2 = 14%), with a moderate level of evidence. Higher doses of alpha2-adrenergic agonists (clonidine/dexmedetomidine) produced more anterograde amnesia than lower doses (n = 2) (RR = 1.83; 95% CI: 1.03-3.25; P = 0.038; I2 = 0%), with a low level of evidence; benzodiazepines' amnestic effects were not dose-dependent (n = 3) (RR = 1.54; 95% CI: 0.96-2.49; P = 0.07; I2 = 12%) but the evidence was low. A qualitative analysis showed that retrograde amnesia did not occur in 8 out of 10 studies. CONCLUSIONS: In children, moderate evidence support that benzodiazepines induce anterograde amnesia, whereas the evidence for other sedatives is weak and based on isolated and small studies. Further clinical trials focused on the amnesia associated with non-benzodiazepine sedatives are therefore needed. TRIAL REGISTRATION: PROSPERO CRD42015017559.

Anterograde amnesia and disorientation are associated with in-patients without traumatic brain injury taking opioids. Retrograde amnesia (RA) is absent. RA assessment should be integral to post-traumatic amnesia testing.

The Glasgow Coma Scale (GCS) only assesses orientation after traumatic brain injury (TBI). 'Post-traumatic amnesia' (PTA) comprises orientation, anterograde amnesia (AA) and retrograde amnesia (RA). However, RA is often disregarded in formalized PTA assessment. Drugs can potentially confound PTA assessment: e.g. midazolam can cause AA. However, potential drug confounders are also often disregarded in formalized PTA testing. One study of medium-stay elective-surgery orthopaedic patients (without TBI) demonstrated AA in 80% taking opiates after general anesthesia. However, RA was not assessed. Opiates/opioids are frequently administered after TBI. We compared AA and RA in short-stay orthopaedic surgery in-patients (without TBI) taking post-operative opioids after opiate/opioid/benzodiazepine-free spinal anesthesia. In a prospective cohort, the Westmead PTA Scale (WPTAS) was used to assess AA (WPTAS<12), whilst RA was assessed using the Galveston Orientation and Amnesia Test RA item. Results were obtained in n=25 (60±14yrs, M:F 17:8). Surgery was uncomplicated: all were discharged by Day-4. All were taking regular oxycodone as a new post-operative prescription. Only one co-administered non-opioid was potentially confounding (temezepam, n=4). Of 25, 14 (56%) demonstrated AA: five (20%) were simultaneously disorientated. Mean WPTAS was 11.08±1.22. RA occurred in 0%. CONCLUSIONS: AA and disorientation, but not RA, were associated with in-patients (without TBI) taking opioids. Caution should therefore be applied in assessing AA/orientation in TBI in-patients taking opioids. By contrast, retrograde memory was robust and more reliable: even in older patients with iatrogenic AA and disorientation. RA assessment should therefore be integral to assessing TBI severity in all formalized PTA and GCS testing.

Transient global amnesia in immediate postoperative period: A diagnostic dilemma.

INTRODUCTION: Transient Global Amnesia (TGA) is short-term inability to form new memories despite otherwise normal neurological function. There is associated anterograde and retrograde amnesia. The memory loss is often accompanied by repetitive questioning and temporal disorientation while higher cognitive functions are preserved. The symptoms usually resolve by 24h. CASE REPORT: We present an interesting case of 31year old female who was planned for robotically assisted right sided pyeloplasty. 30min after emergence from anaesthesia patient was disoriented, with retrograde and anterograde amnesia, but neurological function was intact. Neurologic imaging revealed no abnormality. 36h later patient was able to recall everything. DISCUSSION: The pathogenesis of TGA has more recently been attributed to cerebral venous hypertension resulting from retrograde jugular venous flow. Precipitating events are Valsalva manoeuvre, emotion/stress/pain, Excessive exertion, sexual intercourse and swimming in cold water. CONCLUSION: TGA presents dramatically, it needs to be differentiated from cerebral event. It resolves on its own. But one needs to be aware of existence of such an entity.

Functional (dissociative) retrograde amnesia.

Retrograde amnesia is described as condition which can occur after direct brain damage, but which occurs more frequently as a result of a psychiatric illness. In order to understand the amnesic condition, content-based divisions of memory are defined. The measurement of retrograde memory is discussed and the dichotomy between "organic" and "psychogenic" retrograde amnesia is questioned. Briefly, brain damage-related etiologies of retrograde amnesia are mentioned. The major portion of the review is devoted to dissociative amnesia (also named psychogenic or functional amnesia) and to the discussion of an overlap between psychogenic and "brain organic" forms of amnesia. The "inability of access hypothesis" is proposed to account for most of both the organic and psychogenic (dissociative) patients with primarily retrograde amnesia. Questions such as why recovery from retrograde amnesia can occur in retrograde (dissociative) amnesia, and why long-term new learning of episodic-autobiographic episodes is possible, are addressed. It is concluded that research on retrograde amnesia research is still in its infancy, as the neural correlates of memory storage are still unknown. It is argued that the recollection of episodic-autobiographic episodes most likely involves frontotemporal regions of the right hemisphere, a region which appears to be hypometabolic in patients with dissociative amnesia.

Predicting Retrograde Autobiographical Memory Changes Following Electroconvulsive Therapy: Relationships between Individual, Treatment, and Early Clinical Factors.

BACKGROUND: Loss of personal memories experienced prior to receiving electroconvulsive therapy is common and distressing and in some patients can persist for many months following treatment. Improved understanding of the relationships between individual patient factors, electroconvulsive therapy treatment factors, and clinical indicators measured early in the electroconvulsive therapy course may help clinicians minimize these side effects through better management of the electroconvulsive therapy treatment approach. In this study we examined the associations between the above factors for predicting retrograde autobiographical memory changes following electroconvulsive therapy. METHODS: Seventy-four depressed participants with major depressive disorder were administered electroconvulsive therapy 3 times per week using either a right unilateral or bitemporal electrode placement and brief or ultrabrief pulse width. Verbal fluency and retrograde autobiographical memory (assessed using the Columbia Autobiographical Memory Interview - Short Form) were tested at baseline and after the last electroconvulsive therapy treatment. Time to reorientation was measured immediately following the third and sixth electroconvulsive therapy treatments. RESULTS: Results confirmed the utility of measuring time to reorientation early during the electroconvulsive therapy treatment course as a predictor of greater retrograde amnesia and the importance of assessing baseline cognitive status for identifying patients at greater risk for developing later side effects. With increased number of electroconvulsive therapy treatments, older age was associated with increased time to reorientation. Consistency of verbal fluency performance was moderately correlated with change in Columbia Autobiographical Memory Interview - Short Form scores following right unilateral electroconvulsive therapy. CONCLUSIONS: Electroconvulsive therapy treatment techniques associated with lesser cognitive side effects should be particularly considered for patients with lower baseline cognitive status or older age.

[The evaluation of the retrograde memory in the Quebec population aged: PUB-40 and PUB-12]. / L'évaluation de la mémoire rétrograde dans la population Québécoise âgée: Le PUB-40 et le PUB-12.

Memory assessment represents an important part of the clinical neuropsychologist's duties in a geriatric context. In fact, in Canada, about one-third of seniors report memory complaints, with different causes. Based on the underlying etiology, different components of memory may be affected in older adults. Nonautobiographical retrograde memory (public or semantic) is an important aspect of memory to assess; nevertheless, there is currently no reliable and standardized clinical tool to evaluate this aspect of memory in the elderly Quebecer population. The aims of this research were therefore: (1) to develop a protocol specifically aimed at assessing non-autobiographical retrograde memory in this population, the PUB-40; (2) to obtain reference data among 105 healthy subjects; and (3) to develop a short version based on the items which discriminated a group of 20 patients with amnestic Mild cognitive impairment (aMCI) from older healthy subjects.

Cognitive side-effects of electroconvulsive therapy in elderly depressed patients.

Knowledge about cognitive side-effects induced by electroconvulsive therapy (ECT) in depressed elderly patients is sparse. In this study we investigated changes in the cognitive functioning of non-demented elderly depressed patients receiving ECT (n = 62) compared with healthy elderly people (n = 17). Neuropsychological tests were administered at the start of treatment and again within 1 week after treatment. We computed reliable change indices (RCIs) using simple regression methods. RCIs are statistical methods for analyzing change in individuals that have not yet been used in studies of the acute cognitive side-effects of ECT. At the group level, only letter fluency performance was found to be significantly reduced in the ECT group compared with the controls, whereas both groups demonstrated stable or improved performance on all other measures. At the individual level, however, 11% of patients showed retrograde amnesia for public facts post-ECT and 40% of the patients showed a significant decline in neuropsychological functioning. Decline on a measure of delayed verbal anterograde memory was most common. Our findings indicate that there are mild neurocognitive impairments in the acute phase for a substantial minority of elderly patients receiving ECT. Analysis of reliable change facilitated the illumination of cognitive side-effects in our sample.

Autobiographical memory and electroconvulsive therapy: do not throw out the baby.

Retrograde amnesia for autobiographical information is the most critical adverse effect of electroconvulsive therapy (ECT). Much, if not most, modern research demonstrating long-term autobiographical amnesia after ECT has used either the Columbia University Autobiographical Memory Interview (CUAMI) or the short form of this scale (CUAMI-SF). Semkovska and McLoughlin claimed that studies using these instruments should be dismissed and the findings ignored owing to a lack of normative data, as well as concerns about the reliability and validity of these instruments. In this commentary, the development and use of these scales is reviewed. It is shown that Semkovska and McLoughlin's critique is factually incorrect, as normative data were simultaneously collected in virtually all studies using these instruments. Furthermore, there is substantial evidence supporting the reliability and validity of these scales. Indeed, these instruments are the only neuropsychological tests repeatedly shown to covary with patient self-evaluations of ECT's effects on memory and have repeatedly demonstrated long-term differences in the magnitude of amnesia as a function of ECT technique. Findings with the CUAMI and CUAMI-SF provide key evidence regarding ECT's adverse cognitive effect profile. It is inaccurate and inadvisable to continue to deny that ECT can exert long-term adverse effects in this domain.